157206741-5-1-2023-24-AS-MYAG-CREQQM-20230501122236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157206741
Report Date: 05/01/2023
Date Signed: 05/01/2023 12:22:53 PM

Document Has Been Signed on 05/01/2023 12:22 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:	COMFORT CARE HOME IV		FACILITY NUMBER:	157206741
ADMINISTRATOR:	DHILLON, AMARDEEP (AMY)		FACILITY TYPE:	740
ADDRESS:	4917 AU CHOCOLAT DR		TELEPHONE:	(661) 204-4455
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	6	CENSUS: 4	DATE:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Amy Dhillon, Administrator		TIME COMPLETED:	12:30 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	On 05/01/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA arrived and was greeted by caregiver George Milarion. LPA introduced self, stated the purpose of the visit, and was granted entry. LPA requested to meet with Administrator. Licensee/Administrator Amy Dhillon was called and arrived shortly. LPA conducted tour with Licensee. All four residents were present during inspection. The tour started in the kitchen into the common areas to the resident's rooms. 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: 02/27/23. Medications were checked and observed kept locked in laundry room cabinet. Residents’ MARS was reviewed. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 40 degrees F and freezer temperature at 0-degree F. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. LPA observed 1 shared residents’ bed to be at least 6 feet apart, 2 single occupant rooms, and 1 vacant bedroom. Bathrooms were properly equipped, and the hot water temperature was tested 106.5 degrees F. Hand washing postings was observed. Carbon monoxide and smoke detectors were tested and observed to be operational. Outside of facility toured. Side gate was self-closing and free of debris.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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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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: COMFORT CARE HOME IV	FACILITY NUMBER: 157206741
	VISIT DATE: 05/01/2023

NARRATIVE

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All clients’ file reviewed to have update Emergency contacts, Admission agreement, Pre-Appraisal form, and physician report. All staff's files were also reviewed to have current First Aid/CPR, Personnel Record, Criminal record Statement, and Health Screening.

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: 5/08/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610D, Lic 808, Lic 9282, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of these report.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2023 12:22 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: COMFORT CARE HOME IV	FACILITY NUMBER: 157206741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(3)

A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when LPA and Licensee reviewed all the residents’ MARs and observed all the residents MARs not completed correctly. The staff stated medications for 4/30/23 AM, 04/30/23 PM, and 05/01/23 AM was administered; however the staff did not sign nor initial medications was given for the residents in care this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a plan detailing steps the facility will take to ensure when medications are administered it is documented correctly to the Fresno CCL office. Licensee stated that staff will be re-trained on the requirements of Incidental Medical and Dental Care. Documentation of training topics which will include how medications are administered and how to document after medications are administered. Training topics and staff attendance will be submitted to the Fresno CCL office by 05/08/23.

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: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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