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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247202427
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:27:17 PM


Document Has Been Signed on 05/24/2022 01:27 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:TERRIE'S TLC SENIOR HOME IIFACILITY NUMBER:
247202427
ADMINISTRATOR:RHODES, THERESE ANNEFACILITY TYPE:
740
ADDRESS:1317 E BROOKDALE DR.TELEPHONE:
(209) 726-0548
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:6CENSUS: 1DATE:
05/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Licensee, Therese RhodesTIME COMPLETED:
01:27 PM
NARRATIVE
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On 5/24/2022 Licensing Program (LPA) M. Garza arrived at facility unannounced to deliver complaint findings. LPA was met by facility staff, Christine Jarvise. Licensee was contacted and arrived a short time later. LPA was COVID pre-screened prior to entry to facility. LPA allowed entry to facility and advised reason for visit. LPA toured facility. LPA completed health and safety check on 1 resident in care. Resident observed in common area watching television.

Reporting Requirements discussed. Licensee failed to provide a copy of the death report for R1 in a timely manner. Discussion with Licensee regarding responsibility to report per Title 22 Regulations regarding deaths/special incidents.

During tour of the facility kitchen drawer was found with sharp. This drawer was unlocked and accessible to resident in care.

A deficiency has been cited in accordance with the California Code of Regulations, Title 22. See 809D.
Exit interview was conducted. A copy of this report, appeal rights and deficiency were given.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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 05/24/2022 01:27 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: TERRIE'S TLC SENIOR HOME II
FACILITY NUMBER: 247202427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2022
Section Cited

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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The following requirement was not met as evidence by: LPA observed sharps in an unlocked drawer in the kitchen. This poses an immediate threat to resident in care.
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Type B
06/03/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing...(A) Death of any resident from any cause regardless of where the death occurred...
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This requirement was not met as evidence by LPA observations. LPA reviewed the file of R1. R1's file was incomplete. CCL did not receive a LIC 624A (death report) when R1 passed. Faciilty also failed to report medication was missing when it was brought to their attention by Hospice. This posses a potential 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) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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