157209196-5-15-2023-24-AS-SDOE-CRUSSU-20230515140830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157209196
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:08:51 PM

Document Has Been Signed on 05/15/2023 02:08 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:	TAR SPRINGS HOME CARE		FACILITY NUMBER:	157209196
ADMINISTRATOR:	TELMO, SOCORRO ANN		FACILITY TYPE:	740
ADDRESS:	2804 TAR SPRINGS AVENUE		TELEPHONE:	(661) 831-3430
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93313
CAPACITY:	6	CENSUS: 6	DATE:	05/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Socorro Telmo		TIME COMPLETED:	02:30 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 Socorro Telmo. LPA disclosed the purpose of the visit and was granted entry into the facility by Staff Jesus Ignacio.

A tour of the facility was conducted with the Administrator.

LPA Doucette observed 6 bedrooms in the facility. While touring the facility, Hot water temperature was measured 105.3 F.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked cabinet in kitchen. Cleaning supplies were in a locked cabinet under the kitchen and in locked cabinet in garage. Smoke detectors and carbon monoxide detectors were checked and operating. Facility has a pull station fire alarm. Fire extinguisher has a service date of 12/22/22.

Resident, medication, and staff records were reviewed. R1's centrally stored log was reviewed and errors were observed. R1's records were reviewed and it was observed a bottle of medication with a total count of 30 and a start date of 2/8/23 and the MARS log showing administered daily up until 5/15/23. LPA conducted a pill count with the Administrator for observed errors and found medication had not been given in March, April or May of 2023 for R1. Staff did not have updated training for annual hours required. Administrator is in the process of updating all training 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, Socorro Telmo, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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 05/15/2023 02:08 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: TAR SPRINGS HOME CARE	FACILITY NUMBER: 157209196
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2023

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
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in R1 showing a start date of a medication on 2/8/23 and a pill bottle count of 30 which is prescribed to be administered daily and shows not given for March, April and May of 2023 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Plan of Correction Licensee agrees to submit medication training on administration and logging medication which will include an agenda, qualified presenter and staff signatures by POC due date 5/31/23.

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: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 11

Document Has Been Signed on 05/15/2023 02:08 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: TAR SPRINGS HOME CARE	FACILITY NUMBER: 157209196
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in not logging a medication for R1 since 2/8/23 which only shows a pill count of 30 and should be administered daily which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Plan of correction Licensee agrees to submit an understanding of this regulation and how the regulation will be met by POC due date 5/31/23.

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: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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