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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209103
Report Date: 11/23/2021
Date Signed: 11/24/2021 08:22:26 AM

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:AAA RESIDENTIAL ELDERLY RETREATFACILITY NUMBER:
157209103
ADMINISTRATOR:BELL, ALEXIS EFACILITY TYPE:
740
ADDRESS:4313 MONITOR STREETTELEPHONE:
(661) 213-6798
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY:6CENSUS: 6DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alexis Bell, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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On 11/23/21, 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 met with Administrator Alexis Bell. LPA conduct tour with Administrator. All six residents were present during the inspection.

Facility staff was observed with mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed in facility. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. LPA checked residents’ locked medications. 30-day PPE supplies were observed. LPA observed cleaning chemicals in laundry room unlocked.

Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher not serviced: 02/13/21. LPA observed a bleach in facility office unlocked. LPA toured bathroom. Trash bin in bathrooms was observed with no lid. Securely fastened grab bars observed in bathroom. Hand washing sign observed in bathroom sinks. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 3 shared resident’s bedrooms to be at least 6 feet apart. The exterior tour was conducted. Staff records were reviewed for good health and infection control training. Four out of six residents’ records reviewed to have updated emergency contact information.

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

Exit interview was conducted. A plan of correction was developed and reviewed with the administrator. The following documents are requested and submitted to Fresno CCL by: 12/3/21. The following updated forms were requested: Control of property(lease), Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610D, and Lic 9020. LPA received copy of Administrator certificate during facility inspection. Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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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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: AAA RESIDENTIAL ELDERLY RETREAT
FACILITY NUMBER: 157209103
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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
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Based on observation, the licensee did not comply with the section cited above when LPA observed chemicals unlocked with all 6 residents present during observation, 4 of the 6 residents are ambulatory. Bleach bottle unlocked in the facility office and cleaning chemicals stored in unlocked laundry room accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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Administrator immediately locked the facility office and the laundry room where the bottle of bleach and cleaning chemical was stored. POC cleared during visit
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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