157203951-5-12-2023-24-AS-MYAG-CRRTH2-20230512144401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157203951
Report Date: 05/12/2023
Date Signed: 05/12/2023 02:44:32 PM

Document Has Been Signed on 05/12/2023 02:44 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:	ST. CATHERINE'S HOME CARE, INC.		FACILITY NUMBER:	157203951
ADMINISTRATOR:	NECER, AMALIA		FACILITY TYPE:	740
ADDRESS:	10214 PINNACLE RIDGE AVE.		TELEPHONE:	(661) 665-9405
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	6	CENSUS: 5	DATE:	05/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Caregiver Elias Valentino and Administrator Amalia Necer		TIME COMPLETED:	03:00 PM

NARRATIVE

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On 05/12/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA arrived and was greeted by Caregiver Elias Valentino. LPA introduced self, stated the purpose of the visit, and was granted entry. LPA requested to meet with Administrator. Caregiver and LPA attempted contact via telephone Administrator Amalia Necer. Caregiver and LPA was unable to reach Administrator. LPA conducted tour with caregiver. Administrator Amalia Necer arrrived later during inspection. All five residents were present during inspection.

The tour started in the common areas, to kitchen and into the residents’ bedrooms. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. LPA observed COVID-19 related signs. Fire extinguisher was observed with a service date of: 07/16/19. Medications were checked and observed kept medication drawer. Residents’ MARS was reviewed. Refrigerator temperature maintained at 37 degrees F and freezer temperature at 0-degree F. An adequate supply of perishable and non-perishable food was observed. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. LPA observed 2 shared residents’ bed to be at least 6 feet apart and one single occupant rooms. Bathrooms were properly equipped. Hot water temperature was tested 107.4 degrees F in main bathroom and range from 113.3 to 111.6 degrees F in shared bathroom. Outside of facility toured. Side gate was self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. All residents’ file reviewed to have Admission agreement.

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

LPA will return on a later date to conduct an Annual Continuation inspection to review personnel records.

Exit Interview conducted. A copy of this report and appeal rights was discussed and provided to Administrator Amalia Necer, whose signature on this form confirms receiving this document.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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 05/12/2023 02:44 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
SIERRA CASCADE AC/SC, 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: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87462(h)(2)

87462 (h)(2) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Licensee did not ensure all medications were centrally stored and locked when LPA arrived for inspection and observed R1’s medications in a medication cup on kitchen counter. At approximately 11:08 AM, LPA and caregiver observed two Vitamin bottles and PRN medication Nystatin Topical Powder on R2's personal table in front of the resident in the resident bedroom. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Caregiver immediately removed the medications from R1's personal table and locked in medication drawer. 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 service date of 07/16/2019, which poses an immediate health and safety risk to the residents.
	POC Due Date: 05/13/2023
	Plan of Correction
1 2 3 4	Licensee shall replace or serviced fire extinguisher with a current date. Proof of correction will be submitted to the CCL office by the 05/13/23.

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	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

Page: 9 of 10

Document Has Been Signed on 05/12/2023 02:44 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
SIERRA CASCADE AC/SC, 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: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(2)

87465(c)(2) Incidental Medical and Dental Care Services. Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA reviewed all residents’ MARS and observed that they have not been updated since 05/10/23.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Administrator will submit documentation of staff training with staff rooster of attendance for completing MARS without errors to CCL by the POC due date of 5/25/23.

Section Cited


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

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	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

Page: 10 of 10