107209164-8-23-2024-24-AS-JLEL-D8ETTQ-20240823150106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209164
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:01:12 PM

Document Has Been Signed on 08/23/2024 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	DIGNITY MANOR SENIOR HOME		FACILITY NUMBER:	107209164
ADMINISTRATOR:	GAYNOR, DONTE		FACILITY TYPE:	740
ADDRESS:	1828 SANTA ANA AVE.		TELEPHONE:	(559) 917-0440
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 5	DATE:	08/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator: Camala Kopacz		TIME COMPLETED:	03:30 PM

NARRATIVE

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On 08/23/24 Licensing Program Analysts (LPA) J. Leffall and L. Xiong arrived unannounced to conduct an Annual Inspection. LPAs introduced selves, stated the purpose of the visit, and was greeted by Staff (S1) T. Brownwebb. LPAs was granted entry. 5 clients were present during inspection. Licensee (L1) Camalah Kopacz (L1) arrived shortly after LPA’s arrival.

LPAs toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 37 degrees F. Cleaning chemicals was observed stored and locked under kitchen sink. Fire extinguisher was observed with a service date of: 5/21/24. Fire drill last completed on 08/6/24. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested 105 degrees F. in all 3 bathrooms. Outside of facility toured. Side gates were self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Medications were checked and observed kept locked in medication cart. Clients’ MARS was reviewed. Based on observation Medication 1 (M1) should have 52 tablets. LPA counted 48 tablets. Tablets were 4 short which poses an immediate health, safety or personal rights risk to persons in care. Also, Medication 2 (M2). Medication count should be 89 tablets. LPA’s counted 76 tablets. Tablets were 13 short which poses an immediate health, safety or personal rights risk to persons in care.

Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ file reviewed to have all the required documents. A sample of staff files and all clients’ files were reviewed and observed to have all the required documents.

The following deficiency is in violation of Title 22 CCR.

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 09/6/24: Lic 308, Lic 500, Lic 610D, and Lic 9020. LPA received a copy of current Licensee certificate. A copy of this report was provided to Licensee and Executive, whose signature on this form confirms receipt of these report.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques Leffall	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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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Document Has Been Signed on 08/23/2024 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIGNITY MANOR SENIOR HOME	FACILITY NUMBER: 107209164
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation for Resident 1 (lic 811) Medication L-Thyroxine 50mcg, Dosage Instructions: 1 tablet by mouth 1 time daily. Medication count should be 52 tablets. LPA counted 48 tablets. Tablets were 4 short which poses an immediate health, safety or personal rights risk to persons in care. Also, Medication Mematine 10mg 1 tab by mouth 2 times daily. Medication count should be 89 tablets. LPA’s counted 76 tablets. Tablets were 13 short which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Licensee agrees to have all staff retrained in Medication training and submit written documentation upon completion of training. Licensee agrees to count medications before distributing to resident upon fill date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques Leffall	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

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