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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202411
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:48:53 PM


Document Has Been Signed on 11/04/2022 12:48 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:BLUE PEARL HOME CARE IIFACILITY NUMBER:
157202411
ADMINISTRATOR:PINO, JELYNFACILITY TYPE:
740
ADDRESS:10018 SAINT ALBANS AVENUETELEPHONE:
(661) 412-8164
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 6DATE:
11/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Petro Crisostomo, Licensee TIME COMPLETED:
01:00 PM
NARRATIVE
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On 11/04/22, Licensing Program Analyst (LPA) L. Salazar and Paul Chua, Nurse Evaluator II (NEII) arrived at the facility unannounced to conduct a case management visit. LPA was greeted by caregiver, stated the purpose of the visit and was allowed entry into the facility. Licensee arrived at the facility a few minutes later.

During LPA's visit on 10/25/22, LPA reviewed records for Resident R1. Records show that R1 was admitted into the facility with a prohibited condition without and an approved exception from the Department, while R1 was receiving Home Health services.

LPA and NEII toured the facility and observed Resident R1 to be resting comfortably in their bed. LPA and NEII observed Hospice care being provided by an LVN during the visit.

Based on records review and per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D. If not corrected, the violations will have a direct and immediate risk to the health, safety or personal rights of residents in care.

An exit interview was conducted and Plans of corrections were reviewed and developed with the licensee at the time of visit. Plan of correction was cleared at the time of visit. A copy of this report and appeal rights were discussed and with the licensee.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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 11/04/2022 12:48 PM - It Cannot Be Edited

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: BLUE PEARL HOME CARE II
FACILITY NUMBER: 157202411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2022
Section Cited

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87616 Exceptions for Health Conditions
(b) Written requests shall include, but are not limited to, the following: (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility.
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This requirement was not met as evidenced by LPA's records review and interviews. Facility did not request an exception for a prohibited condition for R1 while R1 was receiving Home Health Care services at the time of admission.
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 LPA printed a copy of the cited regulation to Licensee (L1) during the visit. LPA and L1 reviewed and discussed regulation requirements. LPA obtained a dated signature from licensee verifying the regulation is understood.
**POC Cleared**

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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 HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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