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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206674
Report Date: 09/23/2024
Date Signed: 09/23/2024 01:48:57 PM


Document Has Been Signed on 09/23/2024 01:48 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:AIMES NOBLE IIFACILITY NUMBER:
157206674
ADMINISTRATOR:CORTEZ, JOSEFACILITY TYPE:
740
ADDRESS:5729 NOBLE STREETTELEPHONE:
(661) 589-9992
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:4CENSUS: 3DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Administrator, Jose CortezTIME COMPLETED:
02:00 PM
NARRATIVE
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On 09/23/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff granted LPA entry to the facility and contacted Administrator via telephone. Administrator arrived a short time later. LPA met with Administrator, Jose Cortez.

LPA reviewed facility records and observed the following. LPA found that the facility does not have a current IPP for 3 out of 3 residents and does not have a complete and current record, including a complete admission agreement and medical assessment for 1 out of 3 residents in care. Facility did not have staff records available to review during today's inspection. Based on records, the last fire drill was conducted on 08/17/2024.

LPA conducted a facility tour with Administrator. LPA observed strong odors from incontinence throughout the facility . LPA observed 3 out of 3 couches in the common areas to be in need of repair/replacement. Resident bathrooms were toured. Hot water measured at 113.5 degrees F and 119.3 degrees F. Residents bedrooms appeared to have required furnishings and adequate lighting. LPA observed an adequate supply of linens. Facility kitchen toured. LPA observed an air vent cover in need of repair. Smoke detector and carbon monoxide detector observed to be operational.

Exterior tour conducted. All exits free from obstructions. Side gate was observed to be self-latching. LPA observed a furnished, shaded area outside.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report was discussed and provided to Administrator, Jose Cortez, whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/07/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), Surety Bond

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
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 6


Document Has Been Signed on 09/23/2024 01:48 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: AIMES NOBLE II
FACILITY NUMBER: 157206674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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, the licensee did not comply with the section cited above when 3 out of 3 couches were in need of repair and an air vent cover needs to be replaced, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Licensee agrees to repair or replace the couches and air vents and submit proof of replacement to the Fresno CCL office.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record, the licensee did not comply with the section cited above when personnel records were not available to review during the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87412(f) are met to the Fresno CCL office by the 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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 09/23/2024 01:48 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: AIMES NOBLE II
FACILITY NUMBER: 157206674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

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 when the facility did not have an IPP for 3 out of 3 residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Licensee agrees to submit a copy of the IPP for 3 out of 3 residents in care by the POC due date.
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above when the licensee did not ensure that incontinent residents were kept clean and the facility remains free from odors. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Licensee agrees to submit the facility's plan to ensure that all incontinent residents were kept clean and the facility remains free from odors to the Fresno CCL office by the 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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6