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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247206765
Report Date: 06/25/2021
Date Signed: 06/30/2021 04:04:52 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:NORTHLAKE VILLAFACILITY NUMBER:
247206765
ADMINISTRATOR:SITHIRAJVONGSA,VIENGSAVANHFACILITY TYPE:
740
ADDRESS:3763 N LAKE ROADTELEPHONE:
(209) 761-2180
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:13CENSUS: 11DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Myra TorresTIME COMPLETED:
02:43 PM
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On 6/25/2021 Licensing Program Analyst (LPA) M. Garza arrived at facility to conduct an unannounced Infection Control Inspection. LPA was greeted by Caregiver, Myra Torres after being informed Administrator was not available at this time. Myra was given permission to do visit with LPA. LPA was screened and permitted entry into facility.

LPA observed a central entry point supply of hand sanitizer and sign in policy including documented routine symptom screening for resident's, staff and visitors. Residents observed in common areas watching television, sleeping and in bedrooms. 1 staff was observed not wearing face covering and 2 staff were observed wearing face coverings. Mitigation plan pending approval. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA's toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed in facility. LPA observed a covered trash cans in kitchen, supply of PPE, and cleaning supplies. Residents have 30 day supply of medications. Sinks stocked and liquid soap for hand washing and paper towels observed in kitchen only. LPA observed the following issues during visit: medication/medication log inaccurate; resident without personal belongings; hot water temperature measured at 128 degrees in bathroom; handrails on residents beds; unlocked cabinets with medication, chemicals and sharps accessible to residents; auditory alarms non-functioning; uncovered trash cans in rooms; non-functioning light in dining area and broken switch plate in resident room as a potential fire hazard; unlocked shed with chemicals accessible to residents. LPA observed debris on back patio and in garage. All of this posing a potential harm to residents. Due to time constraints LPA will not be issuing deficiencies for observations but will return for additional visit to issue.

Exit interview completed with Myra. Report signed and a copy will be sent via email. A delivered and read receipt was sent as confirmation of receipt.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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