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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206940
Report Date: 05/18/2022
Date Signed: 05/18/2022 12:29:25 PM


Document Has Been Signed on 05/18/2022 12:29 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:ST. JOSEPH'S HOME, LLCFACILITY NUMBER:
157206940
ADMINISTRATOR:DANO, HAROLD AFACILITY TYPE:
740
ADDRESS:2508 OLMO CTTELEPHONE:
(661) 398-7133
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:6CENSUS: 6DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Harold Dano, Licensee/AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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On 5/18/22 at 9:03 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. LPA met with Licensee (LIC) Harold Dano.

LPA conducted tour with LIC and did not observed any obstructions. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked. LPA checked residents’ medications. Cleaning and PPE supplies were checked. Administrator has current certificate. Staff records checked for good health and training on infection control.

The following deficiencies were observed:
1. LPA observed two knives and one scissor accessible in the sink and on the kitchen counter, one bottle of bleach was left outside accessible on the patio, the centrally stored medication cabinet door was left open and accessible, and hall closet door where cleaning products were stored was left open and accessible while Licensee stepped away to assist a resident.
2. Fire extinguishers last serviced 2/23/21.
3. S1 and S2 did not have proof of TB test results.

The following updated forms to be sent to CCL within 2 weeks: LIC500, LIC610E

Deficiencies are being cited based on LPA's observations and interview in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights were given to Licensee Harold Dano, whose signature confirms receipt of this report.

SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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 3


Document Has Been Signed on 05/18/2022 12:29 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: ST. JOSEPH'S HOME, LLC
FACILITY NUMBER: 157206940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022

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 observations, the licensee did not comply with the section cited above. Both fire extinguishers were last serviced on 2/23/21, which poses an immediate safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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Licensee will submit proof of purchase of new fire extinguishers to CCL by POC due date.
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observations, the licensee did not comply with the section cited above. LPA observed two knives and one scissor accessible in the kitchen sink and on the kitchen counter, one bottle of bleach was left outside accessible on the patio, the centrally stored medication cabinet door was left open and accessible, and hall closet door where cleaning products were stored was left open and accessible while Licensee stepped away to assist a resident, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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Licensee will submit proof of in-service training roster of CCR section 87705 for all staff to CCL by POC due date. LPA provided printed copy of CCR section 87705 to Licensee.

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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/18/2022 12:29 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: ST. JOSEPH'S HOME, LLC
FACILITY NUMBER: 157206940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements – General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. S1 and S2 did not have proof of TB test results, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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Licensee will submit proof of TB test results for S1 and S2 to CCL by POC due date.
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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3