247209209-9-14-2023-24-AS-BCHN-CWL3GX-20231013181504

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247209209
Report Date: 09/01/2023
Date Signed: 09/14/2023 08:47:40 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2023 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20230831094129

FACILITY NAME:	ATWATER RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	247209209
ADMINISTRATOR:	JOHNSON, JESSICA		FACILITY TYPE:	740
ADDRESS:	1691 JOE SILVA AVENUE		TELEPHONE:	(209) 430-1688
CITY:	ATWATER	STATE: CA	ZIP CODE:	95301
CAPACITY:	5	CENSUS: 1	DATE:	09/01/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Facility Staff, Octavia Mcvea		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff are not trained medication management
Facility is not ensuring residents health related needs are met

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA's) Sarah Hurt and Lisa Salazar conducted an unannounced facility visit conduct a Case Management visit. LPA's met with facility staff Octavia Mcvea and explained the purpose of today's visit.

Regarding the allegation Staff are not trained medication management. The Licensee was not able to provide medication training for Staff 1 to LPA's Hurt and Salazar for review. Based on LPA's observation during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230831094129

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 247209209
	VISIT DATE: 09/01/2023

NARRATIVE

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Continued..

Regarding the allegation Facility is not ensuring residents health related needs are met. Licensee was not present at the facility during the visit. Facility staff present was not able to provide Resident 1's records. LPA's Hurt and Salazar observed Staff 1 started on 08/31/23 and is caring for Resident 1 without access to "Needs and Service" plan. Based on LPA's observation during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.

The following Deficiencies are being Cited Per Title 22 Regulations.

Exit interview conducted with Licensee via telephone and a copy of this report was left at the facility.

The Licensee stated the staff present during the visit is not her listed designee and should not sign the report.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230831094129

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 247209209
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/05/2023 Section Cited HSC 1569.69(2)(f)	1 2 3 4 5 6 7	§1569.69 Employees assisting residents with self-administration of medication; training requirements (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.	1 2 3 4 5 6 7	Licensee will provide proof of staff training to LPA Hurt by 09/05/2023 POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by LPAs request for staff and resident files. Licensee was unable to provide files and proof of training at the time of visit. Interviews with staff reveal the required documented training was not conducted. If not corrected, This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
Type B 09/08/2023 Section Cited CCR 87458(b)(1)	1 2 3 4 5 6 7	(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any...other medical conditions which would preclude care of the person by the facility.	1 2 3 4 5 6 7	Licensee will provide Resident 1's file to LPA Hurt by 09/08/2023 POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by LPAs interview with Licensee and staff stating resident file is not available at the time of visit. Staff began employment on 08/30/23 at 4:30pm and does not currently have access to residents care plan which poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

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