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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208933
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:53:46 AM

Document Has Been Signed on 12/15/2022 11:53 AM - 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:NEMIA HOMEFACILITY NUMBER:
157208933
ADMINISTRATOR:GO, CELESTEFACILITY TYPE:
734
ADDRESS:3256 JENKINS RDTELEPHONE:
(650) 238-4987
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 5CENSUS: 4DATE:
12/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Celeste GoTIME COMPLETED:
12:08 PM
NARRATIVE
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12/15/2022, Licensing Program Analyst (LPA) arrived unannounced at the above facility to conduct an case management deficiencies visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Due to COVID-19 precautionary measures, this visit was conducted outside of the facility. LPA met with Administrator, Celeste Go.

On 11/29/2022, the Fresno CCL office was notified that on 09/29/2022, a medication error occurred; facility staff administered the wrong medication to a resident in care. Staff identified the error immediately, monitored the resident, and notified the Administrator and responsible party.

A review of the facility file revealed that the facility did not report the incident to the Fresno CCL office within 7 days following the occurrence of the incident.

Deficiencies are being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Celeste Go, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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 12/15/2022 11:53 AM - It Cannot Be Edited


Created By: Alexandria Walton On 12/15/2022 at 11:31 AM
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: NEMIA HOME
FACILITY NUMBER: 157208933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2022
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications, this requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 80075 are met to the Fresno CCL office by the POC due date.
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Based on review of records the licensee did not ensure the requirements for the above section were met when a resident was given medication meant for another resident, which posses an immediate health and safety risk to residents/clients in care.
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Type B
12/23/2022
Section Cited
CCR80061(b)

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(b) Upon the occurrence... a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report...shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement was not met as evidenced by:
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Licensee agrees to review section 80061 and submit a written statement detailing the steps the facility will take to ensure the requirements for section 80061 are met to the Fresno CCL office by the POC due date.
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Based on review of records, the licensee did not ensure the requirements for the above section were met when the facility did not submit a written report to the Fresno CCL office when a resident was given medication meant for another resident, which posses a potential health and safety risk to residents/clients in care.
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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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022


LIC809 (FAS) - (06/04)
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