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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203951
Report Date: 06/29/2021
Date Signed: 06/30/2021 03:02:10 PM

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:ST. CATHERINE'S HOME CARE, INC.FACILITY NUMBER:
157203951
ADMINISTRATOR:NECER, AMALIAFACILITY TYPE:
740
ADDRESS:10214 PINNACLE RIDGE AVE.TELEPHONE:
(661) 665-9405
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 4DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Amalia Necer, Licensee/AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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On 6/29/21 at 10:30 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA was met by caregivers, explained reason for inspection, and was granted entry. Licensee (LIC) Amalia Necer arrived about 30 minutes later. A tour of the facility was conducted. COVID-19 guidelines are in place. Facility has one main entrance/exit point.

Facility was observed clean and without any obstructions or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms are shared. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked.

The following deficiency was cited:

1. Administrator certificate #6021897740 expired 10/28/2020. Licensee admitted she has not had time to complete the required training for recertification and has not submitted an application for renewal of the Administrator certificate.


2. Licensee could not produce health screenings for S1 and S2.
3. LPA found a shovel, a pair of shears, and four unused metal wire tomato cages in backyard. LPA observed multiple areas of tiled back patio with cracked tiles that had loose shards of broken tile. LPA observed outside fire exit fence gate was stuck, and difficult to unlatch and push open.

Deficiencies are being cited based on LPA observations, record review, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.
Exit interview conducted. A copy of this report and appeal rights were emailed to Licensee Amalia Necer at necerfamily661@aol.com with a read receipt.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 10
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: ST. CATHERINE'S HOME CARE, INC.
FACILITY NUMBER: 157203951
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee could not produce health screenings for S1 and S2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2021
Plan of Correction
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Licensee will submit to CCL health screenings for S1 and S2 showing both staff are in good health, and physically and mentally capable of performing assigned tasks 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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021
LIC809 (FAS) - (06/04)
Page: 2 of 10
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: ST. CATHERINE'S HOME CARE, INC.
FACILITY NUMBER: 157203951
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87407(d)
87407 Administrator Recertification Requirements (d) To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department’s Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Administrator certification for S1 expired on 10/28/2020. Licensee admitted she has not had time to complete the required training for recertification and has not submitted an application for renewal of the Administrator certificate, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2021
Plan of Correction
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Licensee stated she will submit proof of completed application for Administrator recertification and mailing label to show application has been postmarked to Administration Certification Section in Sacramento, by POC due date.
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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021
LIC809 (FAS) - (06/04)
Page: 9 of 10
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: ST. CATHERINE'S HOME CARE, INC.
FACILITY NUMBER: 157203951
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, LPA found a shovel, a pair of shears, and four unused metal wire tomato cages in backyard. LPA observed multiple areas of tiled back patio with cracked tiles that had loose shards of broken tile. LPA observed outside fire exit fence gate was stuck, and difficult to unlatch and push open, all of which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2021
Plan of Correction
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Licensee immediately removed shears and put away in locked drawer. Licensee will remove shovel and four unused metal wire tomato cages from facility premises. Licensee will replace cracked tiles and remove loose shards of broken tiles from back patio area. Licensee will repair outside fire exit fence gate to be able to be opened with ease, and replace latch and cord for latch. All items listed to be corrected by POC due date.
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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021
LIC809 (FAS) - (06/04)
Page: 10 of 10