Community Care Licensing

Document Has Been Signed on 03/03/2025 05:33 PM - It Cannot Be Edited

See Moua TELEPHONE: (559) -65-7912 Mai Yang TELEPHONE: 559-772-7402 DATE: 03/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025

FACILITY NAME: BLUE PEARL HOME CARE II	FACILITY NUMBER: 157202411
	VISIT DATE: 03/03/2025

FACILITY NAME: BLUE PEARL HOME CARE II	FACILITY NUMBER: 157202411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2025

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when LPA, Licensee and S1 observed at 1:40PM, knives stored in kitchen drawer next to the stove unlock. Laundry detergent bottle and two cleaning chemical bottle was observed on top of the dryer in the laundry room unlock. A bottle of bleach was observed on the inside the garage on the side wall unlock. Tools were observed in kitchen drawer under kitchen counter by the medication shelf unlocked and accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2025
	Plan of Correction
1 2 3 4	Licensee immediately locked knife drawer. Staff immediately removed chemicals and tools to lock cabinet in laundry room. POC cleared during visit.

Type A

Section Cited

CCR

87405(d)(2)

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Fire Extinguisher has a last purchase date of 01/29/24, which poses an immediate health and safety risk to the residents.
	POC Due Date: 03/04/2025
	Plan of Correction
1 2 3 4	All fire extinguishers shall be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by POC due date 03/04/25.

See Moua TELEPHONE: (559) -65-7912 Mai Yang TELEPHONE: 559-772-7402 DATE: 03/03/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025

FACILITY NAME: BLUE PEARL HOME CARE II	FACILITY NUMBER: 157202411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2025

Section Cited

CCR

87465(c)(2)

87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews conducted, observation and records reviewed, R1’s medication Duloxetine 60 mg, Amlodipine Besylate 10mg, and Gabapentin 300mg were not administered as prescribed by physician. R2’s medication Fluoxetine Hcl 20mg, Levothyroxine 50mcg, Melatonin 5mg, Mirtazapine 15 mg, Hydroxyzine Hcl 25mg, Atorvastatin 10mg, Escitalopram 10mg, Fluticasone HFA 110mcg, Furosemide 20 mg, and Spironolactone 25mg were not administered as prescribed by physician for which poses an immediate health and safety risk for the person in care.
	POC Due Date: 03/04/2025
	Plan of Correction
1 2 3 4	Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation which will include medication audit, reviewing medication, and training to Fresno CCL office by POC due date 03/04/25. Licensee will have all staff in-service trainings on medications regulations. Licensee will submit documentation of training topics including training date, training materials, training instructor name, and staff attendance rooster to the Fresno CCL office by 3/17/25.

Type A

Section Cited

CCR

87465(d)(3)

87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews conducted, observation, records reviewed, R1’s medication Hydrocodone/ Apap 10/325 mg was not record in the R1’s MAR. R1’s medication Risperidone 25mg, Clopidogrel 75mg were administered on 03/01/25 and 03/02/25, staff did not record on MAR. R2’s medication Atorvastatin 10mg, Melatonin 5mg, and Mirtazapine 15mg were administered on 03/01/25 and 03/02/25, staff did not record on MAR. R2’s medication Fluoxetine Hcl 20mg, Levothyroxine 50mcg, Losartan Potassium 50mg, and Triamcinolone 0.1% cream were administered on 03/02/25, staff did not record on MAR for which poses an immediate health and safety risk for the person in care.
	POC Due Date: 03/04/2025
	Plan of Correction
1 2 3 4	Licensee will ensure to record all medications on resident’s MARs and record when medications are administered. A written statement of steps facility will take to ensure to record each time medications is administered and R1’s medication Hydrocodone/Apap 10/325 mg recorded on R1’s MARs will be submitted to the Fresno CCL by POC due date 03/04/25.

See Moua TELEPHONE: (559) -65-7912 Mai Yang TELEPHONE: 559-772-7402 DATE: 03/03/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025

FACILITY NAME: BLUE PEARL HOME CARE II	FACILITY NUMBER: 157202411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2025

Section Cited

CCR

87608(a)(5)(B)

87608(a)(5)(B) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview conducted and observation, R1 has a full rail bed with no exception granted by the department and no physician order, which poses an immediate health and safety risk to the residents
	POC Due Date: 03/04/2025
	Plan of Correction
1 2 3 4	Licensee agrees submit exception request for full rail bed for R1. Licensee removed full rail from R1's bed. Full rail shall not be used until an exception request is granted by Fresno CCL. POC cleared during visit.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

See Moua TELEPHONE: (559) -65-7912 Mai Yang TELEPHONE: 559-772-7402 DATE: 03/03/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025

FACILITY NAME: BLUE PEARL HOME CARE II	FACILITY NUMBER: 157202411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2025

Section Cited

CCR

87465(h)(6)

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 was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interview conducted, R1’s medication Losartan 50mg bottle filled on 08/28/24 was observed in the resident’s medication basket not recorded in the Centrally Stored Medication Record (Lic 622) which poses/posed a potential health and safety risk for the person in care.
	POC Due Date: 03/04/2025
	Plan of Correction
1 2 3 4	Licensee will ensure to record all resident’s centrally stored medication in the Lic 622. R1’s medication Losartan 50mg bottled filled on 08/28/24 will be recorded in R1’s Lic 622 and submitted to Fresno CCL POC due date 03/04/25.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

See Moua TELEPHONE: (559) -65-7912 Mai Yang TELEPHONE: 559-772-7402 DATE: 03/03/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025