247206554-10-11-2021-24-AS-LCAA-C7PV8J-20211011161249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247206554
Report Date: 10/11/2021
Date Signed: 10/11/2021 04:12:54 PM

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:	KAZLIN INFINITE CARE LLC		FACILITY NUMBER:	247206554
ADMINISTRATOR:	MAGLIBA, ESTRELLITO		FACILITY TYPE:	740
ADDRESS:	3554 EL REDONDO DRIVE		TELEPHONE:	(209) 349-8457
CITY:	MERCED	STATE: CA	ZIP CODE:	95348
CAPACITY:	6	CENSUS: 5	DATE:	10/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:13 AM
MET WITH:	Erlinda Magliba, Designated Representative		TIME COMPLETED:	02:25 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) Lady Cabrera arrived unannounced for an Annual Required Inspection. Administrator Estrellito Magliba was unavailable, however, designated Erlinda Magliba. LPA was met by Designated Representative Erlinda Magliba and stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and beds are six feet apart. The exterior tour was conducted. LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. LPA followed up on an incident reported that occurred on 07/13/2021 regarding Resident (R1) being hit by a branch and getting stuck. Deficiencies are being cited on the attached LIC 809 -D.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

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: KAZLIN INFINITE CARE LLC	FACILITY NUMBER: 247206554
	VISIT DATE: 10/11/2021

NARRATIVE

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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):

 LIC 308 Designation of Facility Responsibility
 -as applicable: LIC 309 Administrative Organization
 -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
 -as applicable: LIC 402 Surety Bond
 LIC 500 Personnel Report
 LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
 LIC 9020 Register of Facility Clients/Residents
 Copy of current Liability Insurance
 Copy of current Administrator Certificate
 Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 10/15/2021 by 12p.m.

Exit interview was conducted. A copy of this report, LIC809, LIC809-D and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

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: KAZLIN INFINITE CARE LLC	FACILITY NUMBER: 247206554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) 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 observation, interview and record review, the licensee did not comply with the section cited above. Licensee did not ensure in trimming the tree, which poses potential health, safety or personal rights risk to persons in care. LPA observed the resident's bathtub was dirty with soap scum.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Licensee service the backyard trees in order to maintain them. Licensee reported her plan of correction is to conduct tree trimming twice a year or as needed. POC Cleared. LPA observed the trees have been service. Licensee will have facility staff clean the resident's bathtub by Friday, 10/15/2021 and will submit photos to CCLD.

Type B

Section Cited

CCR

87412(a)(2)

87412 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: (2) Health screening documents as specified in Section 87411(f). 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. Licensee was uable to provide record of Health Screen for a total of three (3) Health Screen forms at the time of the inspection, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Licensee shall submit Health Screen documents for the three staff by 10/15/2021 to CCLD. Licensee shall a submit a written plan of how to maintain personnel records by 10/15/2021.

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) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC809 (FAS) - (06/04)

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