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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209306
Report Date: 08/28/2023
Date Signed: 08/28/2023 01:02:35 PM

Document Has Been Signed on 08/28/2023 01:02 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PSALMS 23 LOVING CARE RESIDENTIAL IIIIFACILITY NUMBER:
107209306
ADMINISTRATOR:COOLEY, I'ISHAFACILITY TYPE:
735
ADDRESS:2210 S EUNICE AVETELEPHONE:
(559) 270-3822
CITY:FRESNOSTATE: CAZIP CODE:
93706
CAPACITY: 4CENSUS: 3DATE:
08/28/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Vernisha Session, Program DirectorTIME COMPLETED:
01:19 PM
NARRATIVE
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On 08/28/2023, Licensing Program Analyst (LPA) Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self and stated the purpose of the visit and was granted entry to the home. Facility staff contacted Program Director, Vernisha Session, who arrived a short time later.

There were no residents present during the inspection. Per staff, residents were attending day program.

LPA conducted a tour of the facility with facility staff. During the inspection the facility appeared clean and odor free and at a comfortable temperature. Common areas were furnished and had seating and lighting available. LPA observed the door frame leading to the laundry room in need of repair. Resident bedrooms appeared clean. LPA observed that bedroom 2 and 3 were missing night stands and all resident rooms are missing lamps. The dressers under the beds in room 1 and 2 were in need of repair and the bed in room 1 was in need of repair. LPA observed the light bulb in the closet of room 3 needed to be replaced. Residents bathrooms appeared clean, water temperature measured at 145.7 degrees F in bathroom 1 and 145.0 degrees F in bathroom 2. Facility kitchen appeared to be clean and safe for food preparation. LPA observed 2-day supply of perishable foods and a 7-day supply of non-perishable food.

Exterior tour conducted, all exits open and free of obstructions on today’s visit. Fire extinguisher is current with a service date of 01/05/2023. Smoke detectors and carbon monoxide detector observed to operational. Last fire drill conducted on 08/05/2023. Cleaning supplies observed to be locked in a cabinet. LPA reviewed client and staff files. Upon review, LPA did not observe a current IPP for R2 and the physician reports were missing for R2 and R3. Medications observed to be locked and inaccessible to residents in care.

LPA contacted Licensee and requested for P&I records and the personnel file for S1 to be submitted to the Fresno CCL office by close of business today, 08/28/2023.

CONTINUED TO 809C

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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 08/28/2023 01:02 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/28/2023 at 12:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PSALMS 23 LOVING CARE RESIDENTIAL IIII
FACILITY NUMBER: 107209306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when hot water measured at 145.7 degrees F in bathroom 1 and 145.0 degrees F in bathroom 2, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
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Licensee agrees to submit a writtten statement detailing the steps the facility will take to the bring the hot water temperature to 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C), by the POC due date. Licensee will document water temperature for 1 week and submit documentation to the Fresno CCL office by 09/04/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2023 01:02 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/28/2023 at 12:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PSALMS 23 LOVING CARE RESIDENTIAL IIII
FACILITY NUMBER: 107209306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when closet light bulb in room 3 needs to be replaced and the door frame leading to the laundryy room was in need of repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2023
Plan of Correction
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Licensee agrees to make the repairs by the POC due date. LPA will return at a later date to confirm the repairs have been made.
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when the pull out dresser under the beds in room 2 and room 3 were in need of repair and the bed in room 1 was in need of repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2023
Plan of Correction
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Licensee agrees to make the repairs by the POC due date. LPA will return at a later date to confirm the repairs have been made.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 08/28/2023 01:02 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/28/2023 at 12:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PSALMS 23 LOVING CARE RESIDENTIAL IIII
FACILITY NUMBER: 107209306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when 2 out of 3 bedrooms did not have a night stand and 3 out of 3 rooms did not have a lamp or light for reading which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2023
Plan of Correction
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Licensee agrees to purchase a night stand and reading lamps/lights. LPA will return at a later date to confirm required furnishings are in place.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 1 out of 3 residents did not have a current IPP which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee agrees to obtain an updated IPP for R2 and submit a copy to the Fresno CCL office by the POC due date.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 08/28/2023 01:02 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/28/2023 at 12:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PSALMS 23 LOVING CARE RESIDENTIAL IIII
FACILITY NUMBER: 107209306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 2 out of 3 residents did not have a medical assessment on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee agrees to obtain a medical assessment for R2 and R3 and submit a copy of the LIC 602 for R2 and R3 to the Fresno CCL office by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
Page: 5 of 11
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: PSALMS 23 LOVING CARE RESIDENTIAL IIII
FACILITY NUMBER: 107209306
VISIT DATE: 08/28/2023
NARRATIVE
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Based on today's inspection, deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Program Director had a prior obligation and needed to leave the facility. LPA received verbal permission to complete the inspection with Facility Staff, Shannon Senegal.

Exit interview conducted and a Plan of Correction was reviewed and developed with Program Director. A copy of this report and appeal rights were discussed and provided to Facility staff, Shannon Senegal, whose signature on this form confirms receipt of this document.




LPA is requesting the following documents be submitted to the Fresno CCL office by 09/11/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020), Surety Bond
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC809 (FAS) - (06/04)
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