<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206735
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:31:36 PM


Document Has Been Signed on 04/28/2023 03:31 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:RIDGECREST HOME CAREFACILITY NUMBER:
157206735
ADMINISTRATOR:ZAMORA, CRISTINAFACILITY TYPE:
740
ADDRESS:1028 KINNETT AVENUETELEPHONE:
(760) 463-1180
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:5CENSUS: 4DATE:
04/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Adminsitrator Cristina Zamora and Staff Melissa ZamoraTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Shawna Doucette and LPA Brianna Miranda went to the facility unannounced to conduct a 10 day complaint investigation, where other deficiencies were observed during the course of the investigation. LPA conducted a case management to address the deficiencies. LPA met with Licensee/Administrator Cristina Zamora and Staff Melissa Zamora. Licensee/Administrator Cristina Zamora gave permission for Staff Melissa Zamora to sign for this report.

LPA's entered the facility and observed R1 in R1's wheelchair with a postural strap around R1's abdomen restricting R1 to the wheelchair. LPA's requested R1's file, reviewed the file and interviewed staff and were advised R1 does not have a doctor's note prescribing a postural strap for R1.

Upon reviewing R1's file it was observed R1 was prescribed a medication that was listed on the MARS as being administered to R1 with a start date 2/12/23 written on the bottle. The bottle consisted of 90 pills with only 8 pills left in the bottle. LPA checked the centrally stored log which stated the medication was started 11/8/22.
R1 was prescribed another medication where the bottle was empty. The bottle originally contained 90 pills. LPA reviewed the MARS log which stated the prescription was being administered. LPA checked the centrally stored log which stated the medication start date was 10/18/22. After reviewing R1's medication, MARS log and centrally stored log medication errors were observed for both medications.

LPA reviewed staff records for staff that were currently at the facility. After reviewing records and conducting interviews it was found staff did not have current CPR/First Aid. LPA reviewed resident records. After review of records and interviews it was found residents with dementia did not have annually updated LIC 602 physician reports.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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 4


Document Has Been Signed on 04/28/2023 03:31 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: RIDGECREST HOME CARE
FACILITY NUMBER: 157206735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2023
Section Cited

1
2
3
4
5
6
7
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
1
2
3
4
5
6
7
Plan of Correction POC Licensee agrees to submit a written understanding of this regulation and how this regulation will be met by 05/1/23. Licensee will submit physician recommendations for R1 for postural supports by POC due date 05/12/23.
8
9
10
11
12
13
14
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidenced by Licensee had a postural strap to keep R2 in R2's wheelchair without a doctors note which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
05/31/2023
Section Cited

1
2
3
4
5
6
7
87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
1
2
3
4
5
6
7
Plan of Correction POC Licensee agrees to submit current CPR/First Aide training for all staff caring for residents in care by POC due date 5/12/23..
8
9
10
11
12
13
14
This requirement was not met as evidenced by Licensee did not have current CPR/First Aid for both staff at the facility which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/28/2023 03:31 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: RIDGECREST HOME CARE
FACILITY NUMBER: 157206735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2023
Section Cited

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
1
2
3
4
5
6
7
Plan of Correction POC Licensee will submit training agenda by 5/01/23. Licensee agrees to administer medication training to all staff including the logging of centrally stored medications by POC due date 5/12/23.
8
9
10
11
12
13
14
(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by (R2) not recieving one of his medications, however the MARS log was marked the medication was given which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: RIDGECREST HOME CARE
FACILITY NUMBER: 157206735
VISIT DATE: 04/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Deficiencies were observed and were cited under Title 22, Division 6. See LIC 809D.

An exit interview was conducted with Staff Melissa Zamora. A copy of this report, plan of correction and appeal rights were discussed and left with Staff, Melissa Zamora, 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: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4