157209196-5-23-2024-24-AS-SDOE-D5K23G-20240523170220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157209196
Report Date: 05/23/2024
Date Signed: 05/23/2024 05:07:51 PM

Document Has Been Signed on 05/23/2024 05:07 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: 5	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:41 AM
MET WITH:	Administrator Socorro Telmo		TIME COMPLETED:	05:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPA disclosed the purpose of the visit and was granted entry into the facility by Staff Beatriz Ancheta. Administrator Socorro Telmo responded to assist with the visit.

When LPAs arrived staff struggled with unlocking and opening the door. When LPAs entered the facility a separate lock was observed on the front door. LPA asked Administrator why there was a separate lock. Administrator stated they had a resident that wandered and it was to keep the resident in. When LPAs entered the facility there was a smell of urine. Facility had delay egress turned off for the front and garage door. The back door did not have a delay egress. LPA took photos.

A tour of the facility was conducted with Staff.

LPA Doucette observed 6 bedrooms in the facility. While touring the facility, Hot water temperature was measured 106.9 F. Facility is at 76 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 were checked and operating. Carbon monoxide was not working. Facility has a pull station fire alarm. Fire extinguisher has a service date of 1/11/24.

Resident, medication, and staff records were reviewed. R1's centrally stored log was reviewed and errors were observed. Amlodipine and Esomepradole were not logged on the centrally stored log. Morphine prescription showed quantity of 30 however it was crossed out and handwritten in quantity 52. PRN log shows 34 were given out of the 30 or 52 with 23 left. Morphine start date shows 03/4/24. LPA took photos. Staff did not have hospice training for residents on hospice. Hospice care plans did not meet regulation requirements.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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: TAR SPRINGS HOME CARE	FACILITY NUMBER: 157209196
	VISIT DATE: 05/23/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Deficiencies were observed and will be cited under Title 22, Division 6. See LIC 809D. Civil Penalty was issued. 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: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 05:07 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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in Licensee not having a working carbon monoxide detector, which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty issued.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Licensee agrees to have an operating carbon monoxide detector in the facility at all times. Correction completed during visit.

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 record review, the licensee did not comply with the section cited above in Licensee had two different start dates for R1's medication and R1 missed a medication, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct a 2 hour medication training for staff and will submit agenda, what approved training resource was used, who conducted the training and staff trained by POC due date 6/3/24.

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: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 05:07 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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in R1's quantity of 30 label was crossed out and 52 was handwritten in, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct a training on altering the label of a prescribed medication and will submit who was trained who conducted the training and where the approved training resource used and the staff trained by POC due date 4/3/24.

Type A

Section Cited

CCR

87405(a)

Incidental Medical and Dental Care Services

(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Administrator receiving multiple citations and is non compliant in Health and Safety and Title 22 in various areas, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2024
	Plan of Correction
1 2 3 4	Llicensee submit a plan on how these regulations will be met and will become compliant by POC due date 6/3/24.

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: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 05:07 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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in Licensee did not have the front door and the garage door delay egrees turned on and the back door to the backyard did not have a delay egrees, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to keep delay egress on and put a delay egress on the back door by POC due date 6/3/24. Licensee agrees to submit a photo to LPA .

Type A

Section Cited

CCR

87705(l)(3)

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: (3) The licensee shall obtain a waiver from Section 87468(a)(6), to prevent residents from leaving the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation interview, the licensee did not comply with the section cited above in Licensee had an extra lock on the front door to prevent residents from exiting the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Licensee agrees to remove lock. Licensee removed lock during visit. POC cleared.

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: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 05:07 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: 05/23/2024

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) (record review)], the licensee did not comply with the section cited above in Licensee did not log 2 of R1's medications on the centrally stored log, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct a 1 hour training on logging medications and will submit who was trained who conducted the training and where the approved training resource used and the staff trained by POC due date 4/3/24.

Type B

Section Cited

CCR

87606(f)(1)(A)

Care of Bedridden Residents

(f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. (A) The facility's Emergency Disaster Plan, addresses fire safety precautions specific to evacuation of bedridden residents in the event of an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Licensee did not include an evacuation plan of bedridden residents in disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to add to the emergency plan on how to evacuate bedridden residents by POC due date 6/3/24

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: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 05:07 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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87625(b)(3)

Managed Incontinence

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in Licensee did not ensure residents incontinence was changed every 2 hours which caused an odor of urine, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct training on incontinence care and submit resource of training, trainer, agenda, and staff trained by POC due date 6/3/24.

Type B

Section Cited

CCR

87633(a)

Hospice Care for 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 and surgeon and 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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Licensee does not have a care plan that meets the requirements and does not have staff training regarding hospice care for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to get a correct hospice care plan that meets the regulation and staff training for R1's hospice care plan regarding use of oygen and turning R1 by POC due date 6/3/24.

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: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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