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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209189
Report Date: 11/25/2024
Date Signed: 11/25/2024 02:24:52 PM

Document Has Been Signed on 11/25/2024 02:24 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:NANAS CAREFACILITY NUMBER:
157209189
ADMINISTRATOR/
DIRECTOR:		LIBAO, FURAIJA M.FACILITY TYPE:
740
ADDRESS:10301 REVERE BEACH DRIVETELEPHONE:
(901) 262-0260
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 4DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:33 PM
MET WITH:Facility Staff, Leticia SabianoTIME VISIT/
INSPECTION COMPLETED:
02:38 PM
NARRATIVE
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On 11/25/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. Facility staff attempted to contact Administrator, Furaija Libao, but was unsuccessful. LPA conducted the visit with Facility staff.

LPA reviewed facility records and observed the following: client records were reviewed. LPA did not observe a current and complete hospice care plan for R1. Staff files were reviewed and found to be current and complete. Emergency disaster plan on file was not complete. Facility unable to provide the date of the last fire drill. Medications records were reviewed. LPA found that medications were administered as prescribed.

LPA conducted a tour of the facility with facility staff. Common areas were clean and odor free, with adequate seating and lighting available. LPA toured resident bedrooms and found the bedrooms to have required furnishings and adequate lighting. Bathrooms toured and observed to be operational. LPA observed the bathroom to be equipped with securely fastened grab-bars in the shower/toilet areas. Hot water measured at 131.9 degrees F. Kitchen toured and observed to be clean and safe for food preparation. Food supply was checked. Medications were observed to be locked and inaccessible. Cleaning supplies observed to be locked and inaccessible. LPA observed an adequate supply of linens and hygiene products. Smoke detector and carbon monoxide detector observed to be operational during today's inspection. Fire extinguisher last serviced on 01/15/2024.

Exterior tour conducted. Side gate was clear from obstructions. Upon re-entering the facility, LPA observed staff remove a large stick in the sliding track of the living room sliding door. Staff stated the stick is used to prevent the door from being opened.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. 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 Facility Staff, Leticia Sabiano, whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/09/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond, and the facility Infection Control Plan
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 11/25/2024 02:24 PM - It Cannot Be Edited


Created By: Alexandria Walton On 11/25/2024 at 02:01 PM
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: NANAS CARE
FACILITY NUMBER: 157209189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 hot water measured at 131.9 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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Licensee agrees to lower the water temperature and submit a written statement detailing the steps the facility will take to ensure compliance with section 87303(e)(2) to the Fresno CCL office by the POC due date. The statement shall include the facility plan to document water for 1 week and submit a copy of the water log to the Fresno CCL office.
Type A
Section Cited
CCR
87705(l)(6)
87705 Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents

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 a long stick was used to to prevent the sliding door in the living room from being opened which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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Facility staff removed the stick during the inspection. POC cleared during inspection.
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: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/25/2024 02:24 PM - It Cannot Be Edited


Created By: Alexandria Walton On 11/25/2024 at 02:01 PM
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: NANAS CARE
FACILITY NUMBER: 157209189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record revie], the licensee did not comply with the section cited above when facility staff were unable to provide documentation of last fire drill and were unable to provide a date of when the last fire drill was conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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License agrees to submit a statement detailing the steps the facility will take to ensure the requirements are met to the Fresno CCL office by the POC due date.
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
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Based on record review, the licensee did not comply with the section cited above when the facility did not have a current and complete hospice care plan for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87633 are met to the Fressno CCL office by the POC due date. The statement should include the facility's plan to work with the hospice agency to obtain a current and complete care plan.
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: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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