<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 09/21/2023
Date Signed: 11/21/2023 11:59:28 AM


Document Has Been Signed on 11/21/2023 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:ATWATER RESIDENTIAL CARE FACILITYFACILITY NUMBER:
247209209
ADMINISTRATOR:JOHNSON, JESSICAFACILITY TYPE:
740
ADDRESS:1691 JOE SILVA AVENUETELEPHONE:
(209) 430-1688
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:5CENSUS: 2DATE:
09/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Jessica JohnsonTIME COMPLETED:
12:00 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
Regional Manager (RM), Licensing Program Manager (LPM) Brenda Chan, and Licensing Program Analysts (LPA's) Sarah Hurt conducted a Case Management (Office) visit. RO, LPM, and LPA met with facility Administrator Jessica Johnson and explained the purpose of today's visit.

LPA observed Resident 1's medications pre poured in a labeled weekly medication dispenser.

LPA requested records for Resident 1 during a Case Management visit to the facility on 09/12/2023. Licensee Jessica Johnson stated she does not have a file for Resident 1 “because she is new.”

LPA requested the file for Resident 1 be provided by 09/15/2023. Licensee has not provided the file for Resident 1.

Licensee submitted staff training documents

Due to Technical Difficulties this report was not signed by Licensee Jessica Johnson during the visit.


The following Deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Licensee Jessica Johnson, and a copy of this report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 11/21/2023 11:59 AM - 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
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: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2023
Section Cited
CCR
87465(h)(4)

1
2
3
4
5
6
7
87465Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
1
2
3
4
5
6
7
Licensee will conduct medication training with all facility staff, and submit proof to LPA Hurt by 09/22/2023 POC date.
8
9
10
11
12
13
14
Based on LPA observation the facility was dispensing medications not in their orignally marked containers to Resident 1 which poses an immediate, health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14
Type A
09/22/2023
Section Cited
CCR87506(a)

1
2
3
4
5
6
7
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
The following requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide all requested resident records to LPA by 09/22/2023 POC date.
8
9
10
11
12
13
14
Based on observation the Licensee does not have resident records in a location readily available to Licensing staff.
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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/21/2023 11:59 AM - 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
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: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2023
Section Cited
CCR
87465(6)(A)

1
2
3
4
5
6
7
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:(A) The name of the resident for whom prescribed.

(B)The name of the prescribing physician.

(C) The drug name, strength and quantity.

(D) The date filled.

(E) The prescription number and the name of the issuing pharmacy.

(F) Instructions, if any, regarding control and custody of the medication.
The following requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide centrally stored medication log for Resident 1 by 09/22/2023 POC date.
8
9
10
11
12
13
14
LPA Hurt observed Resident 1 does not have a centrally stored medication log which poses an immediate, health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3