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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209360
Report Date: 12/19/2024
Date Signed: 12/19/2024 12:44:44 PM

Document Has Been Signed on 12/19/2024 12:44 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:
12/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:03 PM
MET WITH:Administrator, Minakshi RoychoudhuryTIME VISIT/
INSPECTION COMPLETED:
01:04 PM
NARRATIVE
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On 12/19/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management – deficiencies inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Minakshi Roychoudhury.

The purpose of this visit is to issue citations found during the investigation complaint #20241108113724. Upon review of medications, LPA found multiple medications belonging to resident who no longer resides in the facility that were not destroyed or given to the responsible party. LPA also observed multiple over-the-counter medications stored in the facility and administered when needed. The facility was unable to provide a copy of the prescription and/or physician's order during the inspection.

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

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

During the exit interview, LPA discussed moving the complaint poster to the entrance of the facility as required in Title 22 regulations, updating the LIC500 to include the times when the Administrator will be at the facility, and speak with staff to ensure staff are meeting the care and supervision requirements for all residents in care by knowing where/when residents have appointments or their day program schedules.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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 12/19/2024 12:44 PM - It Cannot Be Edited


Created By: Alexandria Walton On 12/19/2024 at 12:05 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: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2024
Section Cited
CCR
87465(i)

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87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy… shall be destroyed…by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years… this requirement was not met as evidenced by:
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Licensee agrees to write a written statement detailing the steps the facility will take to ensure the requirements of section 87465 are met to the Fresno CCL office. The statement should include the facility’s plan to review and train staff on section 87465. The plan should include a timeframe of when the training will be completed
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Based on observation, the Licensee did not comply with section 87465 when medication belonging to a resident who no longer resides in the facility, was observed co-mingled with current resident medication, which is an immediate health and safety risk to persons in care.
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Type A
12/20/2024
Section Cited
CCR87465(a)(5)(A)

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(a) (5) Facility staff… may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician… this requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing if the facility will remove the over-the-counter medication or obtain a physician’s order for the over-the-counter medication. The statement should include the facility’s plan to not administer any medication or supplements without a physician’s order.
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Based on observation and record review, the licensee did not comply with section 87465 when over-the-counter medication was observed stored in the facility and administered without a prescription from a physician.
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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: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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