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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209360
Report Date: 09/17/2024
Date Signed: 09/17/2024 01:49:30 PM

Document Has Been Signed on 09/17/2024 01:49 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:NORTHWEST VILLAFACILITY NUMBER:
107209360
ADMINISTRATOR/
DIRECTOR:		ROYCHOUDHURY, MINAKSHIFACILITY TYPE:
740
ADDRESS:542 W. BROWNING AVENUETELEPHONE:
(559) 448-8964
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 6DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Licensee, Rajat Choudary and Administrator, Shailesh PatelTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
NARRATIVE
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On 09/17/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator/Licensee via telephone, LPA met with Licensee, Rajat Choudhury..

LPA reviewed resident and staff files. LPA found that 3 out of 6 residents did not have a needs and services plan on file. Staff files were not complete. LPA did not observe documentation for staff training on file.

LPA conducted a facility tour with the Licensee. All passageways were clear from obstructions. Facility appeared to be clean and odor free. Common areas observed to be furnished with adequate lighting. Resident bedrooms were toured. LPA observed safety door knob covers and door reinforcement locks installed on two exit doors. Licensee removed the safety locks during the inspection. Bedrooms were observed to have required furnishings. Bathrooms toured and observed to be operational. Hot water measured at 109.2 degrees F and 113.2 degrees F. LPA observed a bottle of comet under the sink in the bathroom, accessible to residents in care, Licensee removed the disinfectant and placed it in a locked cabinet in the laundry room. Food supply was checked. LPA observed an adequate supply of perishable foods and non-perishable foods. Cleaning supplies is kept in the laundry room. Medications checked and observed to be administered as prescribed. Fire extinguisher was last serviced on 04/10/2023.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed with Licensee. A copy of this report and appeal rights were discussed and provided to Administrator, Shailesh Patel, whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/01/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 09/17/2024 01:49 PM - It Cannot Be Edited


Created By: Alexandria Walton On 09/17/2024 at 01:24 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 a bottle of disinfectant (Comet) was observed under the sink the resident bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2024
Plan of Correction
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Licensee removed the bottle of disinfectant and placed it in a locked cabinet in the laundry room. POC cleared.
Type A
Section Cited
CCR
87405
87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations

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 fire extinguisher was last serviced on 04/10/2023, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Licensee agrees to have the fire extinguisher serviced and submit proof of service 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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/17/2024 01:49 PM - It Cannot Be Edited


Created By: Alexandria Walton On 09/17/2024 at 01:24 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 complete personnel records were not maintained for facility staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Licensee agrees to update and complete personnel records and submit a written statement detailing the steps the facility will take to ensure the requirements for this section are met to the Fresno CCL office by the POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 personnel trainig was not observed on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for this section is met including a timeframe of when all staff will receive required training 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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2024 01:49 PM - It Cannot Be Edited


Created By: Alexandria Walton On 09/17/2024 at 01:33 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: NORTHWEST VILLA
FACILITY NUMBER: 107209360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(I)(6)
87705 Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents

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 additional safety locks were placed on two exits doors prevent residents from leaving which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2024
Plan of Correction
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Licensee removed the locks during the inspection. POC cleared.
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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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