157208816-1-17-2023-24-AS-MYAG-CN6SPF-20230117130304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157208816
Report Date: 01/17/2023
Date Signed: 01/17/2023 01:03:46 PM

Document Has Been Signed on 01/17/2023 01:03 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:	OAK MANOR CARE CENTER		FACILITY NUMBER:	157208816
ADMINISTRATOR:	BRANCH, BRIANNA		FACILITY TYPE:	740
ADDRESS:	9604 VALLEY FOREST CT		TELEPHONE:	(661) 282-5200
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	6	CENSUS: 2	DATE:	01/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Licensee Brianna Branch		TIME COMPLETED:	01:15 PM

NARRATIVE

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On 1/17/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Licensee Brianna Branch and conduct tour with LPA. All two residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. COVID-19 related signs and cough etiquette postings observed.

At 11:27 AM, LPA and Licensee observed cleaning chemicals stored unlocked under kitchen sink and knife observed on kitchen counter. LPA checked residents’ locked medications. LPA and Licensee observed medications stored unlocked in shelf by the dining room. 30-day PPE supplies was observed. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in laundry room. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 2 single occupant room and 2 vacant bedrooms. Bathroom were toured. At 11:47 AM, LPA and Licensee observed a cleaning chemical bottle under bathroom sink. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting not observed by bathroom sinks. LPA observed fire extinguisher served date: 11/3/21. The exterior tour was conducted. Side gate was self-closing and self-latching.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 1/23/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 808, Lic 9282, current Administrator Certificate, control of property and current liability insurance. A copy of this report and appeal rights was provided via email to Licensee. Plan of correction was discussed with Licensee.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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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Document Has Been Signed on 01/17/2023 01:03 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: OAK MANOR CARE CENTER	FACILITY NUMBER: 157208816
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Fire Extinguisher has a service date of 11/3/21, which poses an immediate health and safety risk to the residents.
	POC Due Date: 01/18/2023
	Plan of Correction
1 2 3 4	Licensee shall have fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 1/18/23.

Type A

Section Cited

CCR

87309(a)

Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 observed cleaning chemicals stored under kitchen sink and bathroom sink. LPA and Licensee observed a knife on the kitchen counter next to the sink with utensils unlocked and accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/18/2023
	Plan of Correction
1 2 3 4	Administrator immediately removed and locked cleaning chemicals and knife. Licensee shall review regulations and have staff in-service training regarding regulations to ensure all chemicals and sharps are locked at all times inaccessible to residents in care. Documentation of staff attendance of training and in-service training shall be submitted to department by 1/18/23.

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	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/17/2023 01:03 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: OAK MANOR CARE CENTER	FACILITY NUMBER: 157208816
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA and Licensee observed Licensee's medications stored unlock in shelf in the diningroom which poses an potential health and safety risk to the residents.
	POC Due Date: 01/23/2023
	Plan of Correction
1 2 3 4	Licensee shall review regulations and have staff in-service training regarding regulations to ensure all residents and staff medications are locked and inaccessible to residents in care. Documentation of rooster and in-service training shall be submitted to department by 1/23/23.

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: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

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