Community Care Licensing

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024

Document Has Been Signed on 01/29/2024 03:38 PM - It Cannot Be Edited

FACILITY NAME: HERITAGE CARE HOME	FACILITY NUMBER: 107209251
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

Type A

Section Cited

CCR

87355(e)(2)

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed S1 and S2 working, fingerprinted, cleared and not associated to facility which poses an immediate risk to the health and safety of the residents.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	S1 shift was over and left the facility during inspection. S2 was removed from the facility immediately. S1 and S2 is not permitted back until associated. Licensee to submit LIC 9182 Fingerprint transfer request to Fresno CCL office by POC due date 1/30/24.

Type A

Section Cited

CCR

87411(c)

All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and staff interviews, staff did not have required trainings which poses an immediate risk to the health and safety of the residents.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee stated will provided a written statement of how POC will be completed and submitted to Fresno CCL office by 01/30/24. All staff trainings records of completion shall be submitted to Fresno CCL office by 02/29/24.

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024

Document Has Been Signed on 01/29/2024 03:38 PM - It Cannot Be Edited

FACILITY NAME: HERITAGE CARE HOME	FACILITY NUMBER: 107209251
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

Type A

Section Cited

CCR

87465(h)(5)

Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At approximately 10:30AM, LPA and House manager observed medication tablets for R2 stored inside a zip lock bag and not in original container which poses an immediate risk to the health and safety of the residents.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee agrees to review regulations and submit a written statement understanding regulation 87565 to Fresno CCL office by POC due date 01/30/24.

Type A

Section Cited

CCR

87405(d)(2)

Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Fire extinguisher was observed with a purchased date of 2/28/22, which poses an immediate health and safety risk to the residents.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Fire extinguisher shall be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 01/30/24.

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024

Document Has Been Signed on 01/29/2024 03:38 PM - It Cannot Be Edited

FACILITY NAME: HERITAGE CARE HOME	FACILITY NUMBER: 107209251
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

Type B

Section Cited

HSC

1796.45

Health and Safety Code 1796.45 TB Testing (a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA reviewed S1 did not have a TB result on file which poses a potential risk to the health and safety of the residents.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure all staff have a TB result on file. S1 TB result shall be submitted to the Fresno CCL office by POC due date 02/14/24.

Type B

Section Cited

CCR

87458(a)

Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above when LPA reviewed all residents; file and observed R2 did not have a Physician report assessment on file which poses a potential health and safety risks to persons in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure that all residents have a Physician Report on signed, completed, and on file. Licensee shall submit to obtain Physician report for R2 by POC due date and submit to the Fresno CCL office by 02/14/24.

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024

Document Has Been Signed on 01/29/2024 03:38 PM - It Cannot Be Edited

FACILITY NAME: HERITAGE CARE HOME	FACILITY NUMBER: 107209251
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

Type B

Section Cited

CCR

87465(a)(6)

When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interview with staff, Licensee did not comply with the regulations above by not having a centrally stored medication log for all four resident’s PRN medications and log for PRN medications being administered which poses a potential health safety and or personal rights risk to residents in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Licensee to provide staff training on documenting and logging resident’s medication in centrally stored medication list and in resident’s MARs. Licensee will submit documentation of training topics and staff attendance roster to Fresno CCL office by POC due date 02/14/24.

Type B

Section Cited

CCR

87507(a)

The licensee shall complete an individual written admission agreement for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above when LPA reviewed all residents; file and observed R1 did not have an Admission Agreement which poses a potential health and safety risks to persons in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure that all residents have an Admission Agreement on signed, completed, and on file. Licensee shall have an Admission Agreement for R1 completed and signed by POC due date. Copy of R1’s Admission Agreement shall be submitted to Fresno CCL office by POC due date 02/14/24.

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024