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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202411
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:02:34 PM

Document Has Been Signed on 03/14/2024 03:02 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BLUE PEARL HOME CARE IIFACILITY NUMBER:
157202411
ADMINISTRATOR:CRISOSTOMO, PETROFACILITY TYPE:
740
ADDRESS:10018 SAINT ALBANS AVENUETELEPHONE:
(661) 412-8164
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 5DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee/Administrator Petro Crisostomo TIME COMPLETED:
03:05 PM
NARRATIVE
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On 03/14/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with staff Remedios Karamihan. Licensee/Administrator (L1) Petro Crisostomo was called and arrived shortly. LPA toured facility with L1. All five residents were present during the inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Medications were checked and observed kept locked in kitchen shelf. Residents’ MARS were reviewed. Sharps observed locked under kitchen counter. An adequate supply of perishable and non-perishable food was observed. Fire extinguisher was observed with a service date of: 01/29/24. Cleaning chemicals observed locked in laundry room. Washer and dryer observed operational. Chemicals and garden tools observed unlocked in garage. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested 114.4 degrees F. in master bathroom and 111.7 degrees F in bathroom. Outside of facility toured and observed free of debris. Side gate was self-closing and self-latching. Outdoor seatings observed available for residents. Carbon monoxide and smoke detectors were tested and observed to be operational. All residents and a sample of staff files were reviewed to have all the required documents.

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

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 03/20/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Licensee/Administrator, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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 03/14/2024 03:02 PM - It Cannot Be Edited


Created By: Mai Yang On 03/14/2024 at 02:19 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: BLUE PEARL HOME CARE II
FACILITY NUMBER: 157202411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(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 LPA and A1 observed cleaning chemicals and gardening tools in the garage stored unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Staff immediately removed chemicals to lock shelf and gardening tools off the premises. POC cleared during visit.

Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed.

This requirement was 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 LPA and Licensee reviewed all the residents’ medications and observed multiple medications were not accounted for which poses an immediate health and safety risks to persons in care.

POC Due Date: 03/15/2024
Plan of Correction
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Licensee shall submit a written statement on how Licensee will ensure staff are administering medications as prescribed by POC due date 03/15/24. Licensee shall have all staff retrained in an in-service training on administering medication. Training materials and rooster of staff attendance will be submitted to department by 03/27/23.
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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2024 03:02 PM - It Cannot Be Edited


Created By: Mai Yang On 03/14/2024 at 02:29 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: BLUE PEARL HOME CARE II
FACILITY NUMBER: 157202411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year…

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 resident’s medication and MARs was reviewed and observed medications were not logged into residents’ Centrally store medication log, which poses a potential health, safety or personal rights risk to person in care.
POC Due Date: 03/27/2024
Plan of Correction
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In-service training for all staff shall be completed on documentation of medications. Training materials and rooster of staff attendances shall be submitted to the department by POC due date 03/27/24.

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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
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