157209207-4-26-2024-24-AS-LPAT-D4PMSP-20240426095217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157209207
Report Date: 04/25/2024
Date Signed: 04/26/2024 09:54:04 AM

Document Has Been Signed on 04/26/2024 09:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	YOUR LOVED ONES MATTER LLC		FACILITY NUMBER:	157209207
ADMINISTRATOR:	JIMENEZ, ISAI		FACILITY TYPE:	740
ADDRESS:	4804 KENNY ST		TELEPHONE:	(661) 491-3782
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93307
CAPACITY:	6	CENSUS: 6	DATE:	04/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Isai Jimenez, Administrator/Licensee		TIME COMPLETED:	03:00 PM

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	Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with caregiver Guadalupe Jimenez (GJ) Administrator, Isai Jimenez (AD) was called and arrived shortly thereafter and explained the purpose of the visit. Facility was toured with GJ. During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting. LPA observed required items in the two bathrooms with hot water measuring between 110.3 to 107.2 degrees F. At 10:48am LPA observed what appeared to be dark colored mold on the shower floor, lower tiles and on non skid mat in bedroom 3. At 10:51am LPA observed the sliding glass door in bedroom 3 was shattered on the exterior pane. AD arrived later and explained that the gardener had accidentally shattered it a few days ago. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. Emergency food supply observed. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit reviewed and found to contain required items. Fire Extinguisher located in the kitchen was serviced in June 2023. Smoke detectors in hall, kitchen and bedrooms were tested and Carbon Monoxide detector in hallway was tested in found to be operational. LPA conducted resident and staff file reviews and interviews. LPA observed one staff member’s file to be missing health screening form.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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 10

Document Has Been Signed on 04/26/2024 09:54 AM - 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: YOUR LOVED ONES MATTER LLC	FACILITY NUMBER: 157209207
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation of the shower in resident bedroom 3 which had dark colored mold on the shower floor and lower tiles and non skid mat. LPA observed chicken feces on patio chairs outside and in resident bedroom 3 the one glass of a dual pane sliding glass door is shattered which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Licensee will clean shower and patio chairs and submit photo verification that it has been cleaned to this LPA by the POC due date. LIcensee will repair the glass or replace the sliding glass door in bedroom 3.

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observed there is no window screen in bedroom 2. Licensee explained this was damaged by a resident a few months ago and has not been replaced, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Licensee will replace window screen and submit photo proof to this LPA by the POC due date.

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: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 10

Document Has Been Signed on 04/26/2024 09:54 AM - 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: YOUR LOVED ONES MATTER LLC	FACILITY NUMBER: 157209207
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview with licensee, the licensee did not comply with the section cited above in that the Health Screening form was missing for 1 out of 2 staff files, which poses an immediate health, safety or personal rights risk to persons in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Staff person will be evaluated by a phycisian for the completion of the Health Screening form. Licensee will submit copy of the completed Health Screening form to this LPA by the POC due date.

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: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

Page: 3 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: YOUR LOVED ONES MATTER LLC	FACILITY NUMBER: 157209207
	VISIT DATE: 04/25/2024

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

LPA toured the backyard. At 10:58am LPA observed chicken feces on the patio chairs. Licensee has pet chickens/roosters.
Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and emailed to AD, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 5/3/2024: 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 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

Page: 10 of 10