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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206898
Report Date: 02/16/2024
Date Signed: 02/16/2024 02:16:17 PM

Document Has Been Signed on 02/16/2024 02:16 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:SPRUCE GARDENSFACILITY NUMBER:
157206898
ADMINISTRATOR:STEPHANIE HAROFACILITY TYPE:
740
ADDRESS:13303 NANTUCKET PLACETELEPHONE:
(661) 829-2703
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 5DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Administrator, Stephanie HaroTIME COMPLETED:
02:30 PM
NARRATIVE
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On 02/16/2024, Licensing Program Analyst (LPA) Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and was allowed to enter the facility. LPA requested to meet with the Administrator. LPA met with Administrator, Stephanie Haro.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms had required furnishings. LPA observed small holes in the walls in bedroom 1 and bedroom 2. LPA observed water damage to the ceiling of bedroom 2. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 129.7 degrees F in bedroom 1, 129.3 degrees F in the bathroom near bedroom 3, and 126.5 in the bathroom near bedroom 4 and 5 LPA also observed water damage to the hallway ceiling near bedroom 4 and 5. Kitchen toured. LPA observed an adequate food supply. LPA observed that the refrigerator shelving needs to be repaired and a light bulb needs to be replaced. Exterior tour conducted, all exits open and free of obstructions. LPA observed an outdoor fan needing to be cleaned.

Fire extinguisher serviced on 10/10/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 12/14/2023. All cleaning supplies were observed to be locked and inaccessible to residents in care.

LPA reviewed staff and client records. Upon review of records, LPA found that 5 out of 5 residents did not have a needs and services plan. LPA found that multiple residents did not have signed admission agreements, and R3 did not have an admission agreement for the above facility. Medications reviewed and observed to have original labels and be administered as prescribed.

CONTINUED TO 809C.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2024
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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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: SPRUCE GARDENS
FACILITY NUMBER: 157206898
VISIT DATE: 02/16/2024
NARRATIVE
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LPA is requesting the following documents be submitted to the Fresno CCL office by 03/01/2024: 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 for (LIC9020A), Surety Bond

Based on today's inspection, deficiencies were cited in the areas evaluated and listed on the 809-D according to California Code of Regulations Title 22, Division 6.

An exit interview was conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Stephanie Haro, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 02/16/2024 02:16 PM - It Cannot Be Edited


Created By: Alexandria Walton On 02/16/2024 at 01:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SPRUCE GARDENS
FACILITY NUMBER: 157206898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above when hot water measured between 126.5 degrees F to 129.7 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2024
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 87303(e)(2) are met to the Fresno CCL office by the POC due date. The statement should include the facility's plan to document facility water temperature for 1 week and submit the water temperature record to the Fresno CCL office by 02/23/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2024 02:16 PM - It Cannot Be Edited


Created By: Alexandria Walton On 02/16/2024 at 01:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SPRUCE GARDENS
FACILITY NUMBER: 157206898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

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 the walls in bedroom 1 and 2, the water ceilings in room 2 and the hallway, the refrigerator, outdoor fan, and the light bulb in the kitchen need to clean/reapair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee agrees to clean and repair the items listed and submit proof to the Fresno CCL office by the POC due date.
Type B
Section Cited
CCR
87465(a)(1)
Incidental Medical and Dental Care Services
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

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 5 out of 5 residents did not have a needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Licensee agrees to develop a needs and services plan for 5 out of 5 residents in care and submit all plans 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 Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 02/16/2024 02:16 PM - It Cannot Be Edited


Created By: Alexandria Walton On 02/16/2024 at 01:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SPRUCE GARDENS
FACILITY NUMBER: 157206898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

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 multiple resident did not have signed/date admission agreements and R3 did not have an admission agreement for the above facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Licensee agrees to update R3's admission agreement and sign and date all admission agreements on file by the POC due date. Updated/complete admission agreements will be submitted to the Fresno CCL office by the POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
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