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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209140
Report Date: 12/15/2021
Date Signed: 12/15/2021 03:50:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GAREM ASSISTED LIVINGFACILITY NUMBER:
107209140
ADMINISTRATOR:HOPPER, JOCELYN BAREFACILITY TYPE:
740
ADDRESS:4266 N 9TH STREETTELEPHONE:
(559) 940-9708
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:6CENSUS: 6DATE:
12/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Administrator, Joyce HopperTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced case management visit in response to a death report received from the facility. LPA Williams met with Administrator Joceyln Hopper and discussed the purpose of the visit.

The Department has conducted interviews and record reviews.

Based on the Departments investigation, Resident 1 (R1) left the facility without required staff supervision.

Section 1569.312(a) of the Health and Safety Code (HSC) is being cited on the attached LIC 809D, due to absence of supervision. If not corrected, the violation will have an immediate risk to the health, safety, or personal rights of persons in care.

A civil penalty of $500 will be assessed pursuant to section 1569.49(c)(3) of the HSC. Additional civil penalties are pending and currently under review. The details of the civil penalties will be outlined in a future report to the facility.

LPA Williams reviewed the plan of correction and civil penalty.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GAREM ASSISTED LIVING
FACILITY NUMBER: 107209140
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2021
Section Cited

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1569.312(a) Basic Service Requirements; Every facility required to be licensed under this chapter shall provide at least the following basic services:, (a) Care and supervision as defined in Section 1569.2.

This requirement was not met evident by:
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Based on interviews and record review, the Licensee did not ensure Resident 1 was supervised when leaving the facility, which poses an immediate health and safety risk to person's in care.
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Licensee has agreed to submit the AWOL policy, AWOL training, and monitoring form by 12/22/2021, to the Department.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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