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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208832
Report Date: 05/11/2023
Date Signed: 05/11/2023 03:13:50 PM


Document Has Been Signed on 05/11/2023 03:13 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 LLCFACILITY NUMBER:
157208832
ADMINISTRATOR:CLARK, CATHERINEFACILITY TYPE:
740
ADDRESS:9320 COBBLE MOUNTAIN ROADTELEPHONE:
(661) 397-0885
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:6CENSUS: 5DATE:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Administrator Catherine Clark TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Catherine Clark. LPA disclosed the purpose of the visit and was granted entry into the facility by Staff Vera Lambino.

A tour of the facility was conducted with the Administrator. The residence was set at 73 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 108 F.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked cabinet. Cleaning supplies were in a locked cabinet under kitchen sink. First Aid Kit contained the required supplies. 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 10/12/22.

There was outdoor seating for the residents.

Resident, medication and staff records were reviewed. Medication error was found for R1. Residents did not have pre admission appraisals, reappraisals or needs and service plans in resident records. Centrally stored log did not have a current log for R1. Current first aid and CPR were on file for staff.

Deficiencies were observed and will be cited under Title 22, Division 6. See LIC 809D.



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, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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 19


Document Has Been Signed on 05/11/2023 03:13 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: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

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 in 1 out of 1 residents R1 did not receiveprescribed medication on 5/8/23, 05/09/23, 5/10/23 and 05/11/23 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Licensee agrees to conduct a staff training regarding medication administration and logging of medications and will submit medication training agenda and staff roster by POC due date 06/8/23.
Section Cited
Deficient Practice Statement
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3
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/11/2023 03:13 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: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87633(a)(4)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).

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 in 1 out of 2 Residents did not have a hospice care plan at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Licensee agrees to submit a hospice care plan for R1 and R2 outling the facility staff responsibilities in caring for R1 and R2 by POC due date 5/12/23.

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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/11/2023 03:13 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: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

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 in staff not having triaining in postural supports, restricted conditions or health services, and hospice care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Licensee agrees to submit proof of staff training to meet this regulation by POC due date 6/8/23.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

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 in by not having proof of training for staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Licensee agrees to submit proof initial staff training specified in this regulation for all staff by POC due date 6/8/23.
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 19


Document Has Been Signed on 05/11/2023 03:13 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: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

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 in pre admissions appraisals for resdients in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Licensee agrees to submit a written statement on the understanding of this regulation and how it will be met in the future by POC due date 06/8/23.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

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 in not having an appraisal for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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3
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Licensee agrees to complete and submit to licensing appraisals for all residents in care by POC due date 06/08/23
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 5 of 19


Document Has Been Signed on 05/11/2023 03:13 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: 05/11/2023

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
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Based on interview and record review, the licensee did not comply with the section cited above in not having listed training needed or trainings provided to staff for R1 and R2 or how the hospice plan will be implemented, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee agrees to obtain written documentation on the trainings needed for staff to care for R1 and R2, which include the use of a hoyer lift needed for R1 and the use of oxygen for R1 and R2 and will include the responsibilities of the Licensee for implementation by POC due date of 5/15/23.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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 PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 6 of 19