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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209196
Report Date: 03/14/2024
Date Signed: 03/14/2024 07:35:37 PM


Document Has Been Signed on 03/14/2024 07:35 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 CAREFACILITY NUMBER:
157209196
ADMINISTRATOR:TELMO, SOCORRO ANNFACILITY TYPE:
740
ADDRESS:2804 TAR SPRINGS AVENUETELEPHONE:
(661) 831-3430
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:6CENSUS: 5DATE:
03/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Administrator Socorro TelmoTIME COMPLETED:
07:45 PM
NARRATIVE
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On 03/14/24, Licensing Program Analysts (LPA) L. Salazar and S. Doucette arrived at the facility unannounced to conduct a 10 day visit. LPAs were greeted by caregiver and were allowed entry into the facility. Administrator arrived to the facility shortly after.

LPAs toured the facility and observed 5 residents in care. 1 out of the 5 residents was observed in a hospital bed with full bed rails. A physician's order to admit R1 on Hospice care was observed, however, no Dr's signature is observed on the order and no Hospice care plan was in file. R1 was observed to have 2 unstageable pressure injuries on each heel.

Resident R2 was observed in a hospital bed with half bed rails. Administrator stated R2 was on Hospice, however, no hospice care plan was observed on file. LPA observed a paper from Traditions Health admitting R2 to Hospice, however, there is no doctor signature on the order. LPAs observed residents in care to have dementia. LPAs observed 2 hours of dementia training in file for Staff S1.

Based on today’s visit, deficiencies are being cited, per California Code of Regulations, Title 22, Division 6, Chapter 8 on the attached 809D.

An exit interview was conducted with Administrator. A copy of this report and appeal rights were discussed and provided at the time of visit. A plan of correction was developed and reviewed by Administrator with a POC date of 03/15/24.


SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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 3


Document Has Been Signed on 03/14/2024 07:35 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: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
87633(a)(4)

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87633 Hospice Care of 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...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).
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Administrator will submit Hospice Care plan for Resident R1 by POC date of 03/15/24. Hospice agency deliverd the hospice care plan for R2 during LPAs visit.
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This requirement was not met as evidenced by LPAs records review and interview with Administrator. There are no hospice care plans in resident files. If not corrected, this poses an immediate Health and Safety risk to residents in care.
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Type A
03/15/2024
Section Cited
CCR87608(a)(5)(B)

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87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself Postural supports may be used under the following conditions.
(5) Under no circumstances shall postural supports include ...(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Administrator will submit Hospice Care plans for Resident R1 that includes order for full bed rails. Resident R2 by POC date of 03/15/14.
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This requirement was not as evidenced by LPAs observation of records. There is no order in Resident R1's file for full bed rails. If not corrected, this poses an immediate Health and Safety risk to residents 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 HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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