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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 147202751
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:38:49 PM

Document Has Been Signed on 08/15/2024 02:38 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:INYO-MONO ASSOCIATION FOR THE HANDICAPPEDFACILITY NUMBER:
147202751
ADMINISTRATOR/
DIRECTOR:		RICO, ADELINAFACILITY TYPE:
775
ADDRESS:371 SOUTH WARREN STREETTELEPHONE:
(760) 873-8668
CITY:BISHOPSTATE: CAZIP CODE:
93514
CAPACITY: 30CENSUS: 11DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator Adelina RicoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette and Sarah Hurt arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Program Director Adelina Rico. LPA disclosed the purpose of the inspection and was granted entry into the facility by Program Director Adelina Rico.

A tour of the facility was conducted with Program Director Adelina Rico. The facility was set at 68 F temperature and free of passageway obstructions inside and outside. The water temperature was measured at 127.0 F.

Kitchen was toured. Cleaning supplies were in a locked storage room. Smoke detectors and carbon monoxide detectors were checked and operating. Facility is wired with sprinkler system. Fire extinguishers were charged and had service dates of 06/15/24. Fire drill was last completed on 1/16/24 and earthquake 3/12/24..

Client and staff records were reviewed. Current first aid and CPR were on file for staff. MARS log for C1 does not match amount of medication left to the amount administered. Medication started on 6/12/24 and 31 pills were logged. Since that date according to MARS log 36 pills were administered. There are still 11 pills left in bottle.

An exit interview was conducted with the Program Director and a copy of this report with was provided with plans of correction and appeal rights. .

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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 08/15/2024 02:38 PM - It Cannot Be Edited


Created By: Shawna Doucette On 08/15/2024 at 12:16 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: INYO-MONO ASSOCIATION FOR THE HANDICAPPED
FACILITY NUMBER: 147202751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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 in Licensee did not meet this regulation by water measuring 127 F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee agrees to send a picture to licensing of water temperature ranging between 105 F and 120 F by POC due date 8/16/24.
Type A
Section Cited
CCR
82075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review], the licensee did not comply with the section cited above in Licensee did not properly administer C1's medications, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee agrees to conduct a medication training with staff by 8/23/24. Licensee agrees to submit copy of training and sign in sheet by 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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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