167202502-7-14-2022-24-AS-KKAR-CGBTGQ-20220714144332

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 167202502
Report Date: 07/14/2022
Date Signed: 07/14/2022 02:44:46 PM

Document Has Been Signed on 07/14/2022 02:44 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:	HANNA'S HOME CARE		FACILITY NUMBER:	167202502
ADMINISTRATOR:	FELLEKE, HANNA		FACILITY TYPE:	740
ADDRESS:	2427 CHERRYWOOD CT.		TELEPHONE:	(559) 583-6880
CITY:	HANFORD	STATE: CA	ZIP CODE:	93230
CAPACITY:	6	CENSUS: 1	DATE:	07/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:31 PM
MET WITH:	Administrator Hanna Felleke		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	On 07/14/2022, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry by Administrator Hanna Felleke. Facility staff was observed with face coverings. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Social distancing and cough etiquette postings observed in facility. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Fire extinguisher in kitchen was last serviced on 02/22/2022 and was fully charged. One resident’s bedroom toured and observed to be adequately furnished and well lit. Other 2 resident bedrooms are vacant. LPA toured bathrooms and observed Trash bins with lids and hand washing signs. LPA checked residents’ locked medication and observed a 30-Day supply of PPE and incontinence supplies. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. At 1:00PM LPA observed laundry area to be unlocked with laundry detergent, bleach, and cleaning supplies. Staff records were reviewed for good health and infection control training. Residents’ records reviewed to have updated emergency contact information. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. LPA is requesting the following documents be submitted to the Fresno CCL office by 7/21/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Continued on LIC809C

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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 07/14/2022 02:44 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: HANNA'S HOME CARE	FACILITY NUMBER: 167202502
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 when LPA observed a bleach bottle, laundry soap and other cleaning chemical bottles stored in an unlocked laundry cabinet in the laundry room accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/15/2022
	Plan of Correction
1 2 3 4	Administrator immediately removed the items to a locked cabinet. POC cleared during visit.

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: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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: HANNA'S HOME CARE	FACILITY NUMBER: 167202502
	VISIT DATE: 07/14/2022

NARRATIVE

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Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided to Administrator, whose signature on this report confirms receipt of these documents.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC809 (FAS) - (06/04)

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