247206554-9-29-2022-24-AS-LCAA-CJQRD7-20220929125529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247206554
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:55:58 PM

Document Has Been Signed on 09/29/2022 12:55 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:	KAZLIN INFINITE CARE LLC		FACILITY NUMBER:	247206554
ADMINISTRATOR:	ERLINDA MAGLIBA		FACILITY TYPE:	740
ADDRESS:	3554 EL REDONDO DRIVE		TELEPHONE:	(209) 349-8457
CITY:	MERCED	STATE: CA	ZIP CODE:	95348
CAPACITY:	6	CENSUS: 4	DATE:	09/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Maria Flores, Staff		TIME COMPLETED:	01:15 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. LPA met with Staff Maria Flores. Administrator Erlinda Magliba was out of town and unavailable. LPA spoke with Administrator and she approved for Staff to conduct the tour of the facility and to sign this report. LPA 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. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathrooms. Bedrooms were checked. 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. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Deficiencies cited on LIC809D. Exit interview was conducted and Appeal Rights were provided.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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 09/29/2022 12:55 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: KAZLIN INFINITE CARE LLC	FACILITY NUMBER: 247206554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2022

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 cleaning chemicals spray bottle under unlocked bathroom and kitchen sink. LPA observed unlocked kitchen knives near the sink, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2022
	Plan of Correction
1 2 3 4	Care Staff immediately removed cleaning disinfectants, cleaning solutions, and knives and locked it in a 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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/29/2022 12:55 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: KAZLIN INFINITE CARE LLC	FACILITY NUMBER: 247206554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2022

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 observations, the licensee did not comply with the section cited above. LPA observed several unused wheelchair, walkers, boxes and various items in the garage blocking the pathway. Garage door has two door locks from the inside of the facility to enter the garage, which residents can turn the locks and have access to the garage, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2022
	Plan of Correction
1 2 3 4	Licensee shall remove all items or organize the garage and clear a pathway. Licensee will submit pictures to CCL by 10/13/2022.

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: Lady Cabrera	TELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: 09/29/2022

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: 10/06/2022.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

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