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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204184
Report Date: 11/18/2022
Date Signed: 11/18/2022 01:47:12 PM


Document Has Been Signed on 11/18/2022 01:47 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:LERWICK HOME CAREFACILITY NUMBER:
157204184
ADMINISTRATOR:ROSALES, BONAFEFACILITY TYPE:
740
ADDRESS:10213 LERWICK AVENUETELEPHONE:
(661) 665-2874
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Socorro Telmo, Administrator TIME COMPLETED:
02:00 PM
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On 11/18/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Susan Gonzales, Caregiver. Socorro Telmo, Administrator was called and arrived shortly and conduct tour with LPA. All five residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed COVID-related signs and cough etiquette posting.LPA observed small amount of PPE supplies in facility.LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage. LPA observed fire extinguisher served date: 03/22/22. All resident’s room toured and observed to be adequately furnished and lit. LPA observed two shared residents’ bed to be at least 6 feet apart and two single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with no lid. Hand washing posting observed by bathroom sinks. LPA and Administrator observed cleaning chemical bottles stored under bathroom sink unlocked.The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information.

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: 11/25/22. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, Control of Property, and current liability insurance. LPA received a copy of current Administrator certificate.A copy of this report and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
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 11/18/2022 01:47 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: LERWICK HOME CARE
FACILITY NUMBER: 157204184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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 Administrator observed cleaning chemicals stored under bathroom sink unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2022
Plan of Correction
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Administrator immediately locked bathroom sink. POC clear during visit.
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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