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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204221
Report Date: 04/17/2024
Date Signed: 04/17/2024 02:31:23 PM


Document Has Been Signed on 04/17/2024 02:31 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:SUMMER SPRINGS BOARD & CAREFACILITY NUMBER:
157204221
ADMINISTRATOR:SOCORRO TELMOFACILITY TYPE:
740
ADDRESS:6112 SUMMER SPRINGS DRIVETELEPHONE:
(661) 397-0416
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:6CENSUS: 6DATE:
04/17/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Socorro TelmoTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Socorro Telmo.

During yesterday's visit LPA's toured the facility. LPA Doucette observed 4 bedrooms in the facility. While touring the facility, LPA observed an added staff bedroom/office/garage which was not on the facility sketch and was not fire cleared. Facility had two different facility sketches posted in the facility. The first sketch did not identify a caregiver room. The second sketch identified the caregiver room as bedroom 1 where residents reside. LPA pulled the sketch from licensing file which does not identify a caregiver room. The staff bedroom/office/ garage contained a fully made bed with sheets and blanket, a recliner and filing cabinets. Facility did not have plan of operation at the facility.

Hot water temperature was measured 115 F. Bathroom did not have skid mats but had grab bars. Facility staff purchased skid mats during visit.

Kitchen toured, supply of food observed. Carrots were expired October 2023. Knives were locked in kitchen drawer. Medications were stored in a Medication cart which was found to be unlocked in the dining room. Refrigerator for medications were found to be unlocked containing morphine and insulin in the dining room. LPA's took photos. Cleaning supplies were in a locked cabinet under the kitchen and bathroom sinks. Smoke detectors and carbon monoxide detectors were checked and operating.

Resident, medication, and staff records were reviewed. R3's centrally stored log was reviewed and errors were observed. One of R3's narcotic medications was not logged. R1's records were reviewed and it was found that R1 self administers injections. R1 had a sharps container in a shared room with R2, which made sharps accessible to R2. Facility does not have a Home Health Care Plan for R2. Facility did not have a Hospice Care Plan for R4.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
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 04/17/2024 02:31 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: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in having a staff room/office in the garage that is not fire cleared, which poses an immediate health, safety or personal rights risk to persons in care. LPA took photos.
Cvil Penalty issued.
POC Due Date: 04/18/2024
Plan of Correction
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Licensee agrees to remove the fully made bed for staff to sleep in or agrees to submit documents to have the room fire cleared by POC due date 04/18/24.
Type A
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.

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 by licensee having a syringe box that is in R1's shared room with R2 accessible to R2, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Licensee agrees to lock up sharps and make them inaccessible to residents. Licensee agrees to submit a written plan on how this regulation will be met by POC due date 04/18/24.

Civil Penalty issued.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 02:31 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: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)
Adminstrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview record review, the licensee did not comply with the section cited above due to the amount of citations Administrator is not meeting the requirements of this regulation, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Licesnee agrees to submit a plan in writing on how the Administrator will meet the qualifications in this regulation from 1 to 7 by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) 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 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 in by not having the medication cart locked and not having the medication refridgerator locked containing morphine and insulin which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Licensee agrees to conduct medication training for all staff. Licensee agrees to submit who will conduct the training and the agenda for the training regarding locked medications by POC due date 04/18/24
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 02:31 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: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(1)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview record review, the licensee did not comply with the section cited above by not having a plan for daily meals for residents with modified diets, facility staff could not answer what residents were eating for dinner which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to conduct staff training on meal preparation to meet the needs of the residents by POC due date.
Section Cited
Other Provisions
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 02:31 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: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 by having bags of expired carrots expiring 10/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to dispose of expired food by POC due date 04/26/24. LPA will clear POC during visit.
Type B
Section Cited
CCR
87555(b)(7)
General Food Service Requirements
(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview record review, the licensee did not comply with the section cited above by Licensee not having a diabetic diet for R1 and a low sodium diet for R3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to submit a sample menu for a low sodium diet and a diabetic diet by POC due date 04/26/24.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 02:31 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: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview record review, the licensee did not comply with the section cited above in Licensee did not have a bottle of oxycodone logged on centrally stored log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to submit in writing on how this regulation will be met in the future and agrees to submit a copy of the medication showing logged on the centrally stored log by POC due date 4/26/24

Civil Penalty issued.
Type B
Section Cited
HSC
1569.725(a)(4)
Levels of Care
(a)  A residential care facility for the elderly may permit incidental medical services to be provided through a home health agency, licensed pursuant to Chapter 8 (commencing with Section 1725), when all of the following conditions are met: (4)  There is ongoing communication between the home health agency and the residential care facility for the elderly about the services provided to the resident by the home health agency and the frequency and duration of care to be provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview) record review, the licensee did not comply with the section cited above in Licensee did not have a home health care plan for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to submit a plan of care to meet the regulations by POC due date 04/26/24.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 02:31 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: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87609(b)(4)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview record review, the licensee did not comply with the section cited above in Licensee did not have in writing the responsibilities of Home Health and the responsibilities of facility staff for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to have a plan in writing from the home health agency listing the responsibilities of home health and of the facility staff in caring for R2's medical condition by POC 04/26/24.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 02:31 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: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(4)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).

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 in R4 not having a Hospice care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to submit a copy of R4's hospice care plan by POC due date 04/26/24.

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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 02:31 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: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)(6)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above Licensee did not have training for R1's diabetic diet or for R4's medical conditions, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to obtain training through Hospice on how to meet the medical needs of R1 and R4.

Civil Penalty issued.
Type B
Section Cited
CCR
87633(h)(5)
Hospice Care for Terminally Ill Residents
(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (5) A statement signed by the resident's roommate, if any, or any resident who will share a room with a person who is terminally ill to be accepted or retained as a resident, indicating his or her acknowledgment that the resident intends to receive hospice care in the facility for the remainder of the resident's life, and the roommate's voluntary agreement to grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy, and others.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on record review, the licensee did not comply with the section cited above by licensee not having an agreement signed by R2 for a shared room with R1 who is on Hospice which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
1
2
3
4
Licensee agrees to have the agreement signed by POC due date 04/26/24.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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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: SUMMER SPRINGS BOARD & CARE
FACILITY NUMBER: 157204221
VISIT DATE: 04/17/2024
NARRATIVE
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Staff have current first aid and CPR training. Staff did not have training logged correctly. Training was missing hours and dates. Facility staff did not have training from Hospice for R4. Administrator was not able to provide intial staff training for staff.

During today's visit Administrator was able to provide plan of operation and plan of operation for dementia. LPA rechecked the medication cart and two drawers were unlocked with medication. LPA took photos.

LPA educated Licensee/Administrator on where to locate care tool to assist Licensee/Administrator in becoming compliant.

Refer to 809D for deficiencies. Civil Penalties were issued for repeat violations.

An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeal rights were discussed and left with the Administrator, Socorro Telmo, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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