157208832-4-23-2024-24-AS-SDOE-D4LSV9-20240423141223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157208832
Report Date: 04/23/2024
Date Signed: 04/23/2024 02:14:48 PM

Document Has Been Signed on 04/23/2024 02:14 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:	COBBLE STONE RESIDENTIAL HOME CARE LLC		FACILITY NUMBER:	157208832
ADMINISTRATOR:	CLARK, CATHERINE		FACILITY TYPE:	740
ADDRESS:	9320 COBBLE MOUNTAIN ROAD		TELEPHONE:	(661) 397-0885
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93313
CAPACITY:	6	CENSUS: 5	DATE:	04/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Catherine Clark		TIME COMPLETED:	12:45 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 arrived at the facility unannounced to conduct the Required Annual Inspection. LPA disclosed the purpose of the visit and was granted entry into the facility by Staff Maribel Albandie. Administrator Catherine Clark responded to the facility to conduct the visit.

A tour of the facility was conducted with the Administrator. The residence was set at 75 F temperature and free of passageway obstructions inside and outside. LPA Doucette observed 4 bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean. Hot water temperature was measured 105 F. Computer room was being used as a staff bedroom and does not show on facility sketch as a fire cleared bedroom.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked cabinet in the dining room area. Cleaning supplies were unlocked in a cabinet in the laundry room. Smoke detectors and carbon monoxide detectors were checked and operating. Facility has a pull station fire alarm. Fire extinguishers were charged and had service dates of 10/21/23.

There was outdoor seating for the residents.Outdoor shed was unlocked containing pesticides.

Resident, medication and staff records were reviewed. Medication error was found for R1. Resident prescription was crossed out where it shows the description of how the prescription should be administered. Facility staff wrote two different start dates on the prescription. LPA took photos. R1 did not have a Hospice Care Plan. Mars log did not have a current log for R1 pertaining to the medication with the two start dates.

Current first aid and CPR were on file for staff. Staff did not have training for R1's Hospice Care.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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 6

Document Has Been Signed on 04/23/2024 02:14 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: COBBLE STONE RESIDENTIAL HOME CARE LLC	FACILITY NUMBER: 157208832
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above Licensee crossed out the instructions from the pharmacist on the prescription which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Plan of Correction Licensee agrees to submit a written statement as to the understanding of this regulation by POC due date 04/26/24.

Type B

Section Cited

CCR

87633(b)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above Licensee did not have a Hospice Care Plan for R1 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a copy of R1's Hospice Care Plan by POC due date 5/3/24.

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 04/23/2024 02:14 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: COBBLE STONE RESIDENTIAL HOME CARE LLC	FACILITY NUMBER: 157208832
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(b)(6)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above Licensee did not have staff training for R1's Hospice Care with morphine and oygen which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit proof of training for staff for R1's care by 5/3/24.

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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 04/23/2024 02:14 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: COBBLE STONE RESIDENTIAL HOME CARE LLC	FACILITY NUMBER: 157208832
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

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
1 2 3 4	Based on [(observation) (interview), the licensee did not comply with the section cited above in Licensee turned a computer room into a caregiver bedroom which does not show on the facility sketch which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit LIC 200, facility sketch and LIC9054 by POC due date 04/26/24.

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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: COBBLE STONE RESIDENTIAL HOME CARE LLC	FACILITY NUMBER: 157208832
	VISIT DATE: 04/23/2024

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 will be cited under Title 22, Division 6. See LIC 809D. Civil Penalty was issued. An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeal rights were discussed and left with the Administrator, Catherine Clark, and a copy of this report will be emailed.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

Page: 6 of 6