247209209-7-13-2022-24-AS-AWAN-CFGT6J-20220617142712

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 06/17/2022
Date Signed: 07/13/2022 12:16:56 PM

Document Has Been Signed on 07/13/2022 12:16 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/13/2022 12:14 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

NARRATIVE

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This is an amended report.

On 06/17/2022, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct a Post-Licensing Inspection. LPA introduced self, stated that purpose of the visit and was granted entry to the facility. LPA met with Assistant Administrator, Denise Ordonez and Administrator, Jessica Johnson. Facility currently has 3 residents in care.

LPA conducted a tour inside and outside the facility with Administrator. Facility observed to be clean, odor free, and at a comfortable temperature. The dining room and living room were furnished well with adequate seating and lighting. Resident rooms appeared clean and had all required furnishings. 1 bedroom is single occupant, the second resident bedroom is shared, beds were observed to be at least 6 feet apart. LPA observed an adequate supply of linen. Facility has an adequate supply of PPE and cleaning supplies. Resident bathrooms were properly equipped with securely fastened grab bars and non-skid mats. Bathrooms were stocked with liquid soap and paper towels. Hand-washing signs observed by bathroom sinks. Hot water in 3 bathrooms measured between 109.3 - 119.3 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable foods. Facility did not have a 2-day supply of perishable food. Knives/Sharps observed to be locked in the medication cabinet. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 03/21/2022. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has not conducted a fire drill as of this date. All chemicals observed to be locked and secure laundry room. Medications observed to be locked in a cabinet in the kitchen.

LPA reviewed resident records and medications. Review of medications revealed that R1 has not received R1's medication of Sertraline HCL 50MG for the past 8 days. MARs observed to be signed off as given. LPA observed that R2 is missing 2 PRN medications, Acetaminophen and Hyosclamine.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

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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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: ATWATER RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 247209209
	VISIT DATE: 06/17/2022

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LPA reviewed personnel files for first aid and criminal record clearance. Administrator has been unable to provide documentation for proof of staff training.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted with Administrator.

A Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Jessica Johnson, whose signature on this form confirms receiving this document.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/13/2022 12:13 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/13/2022 12:08 PM

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: ATWATER RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 247209209
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above when 2 out of 2 staff did not have documentation to prove staff received initial training prior to working in the faciltiy, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written statement detaling how each employee will receive training prior to working in the facility. Licensee will have 2 out of 2 employees complete the initial training submit a copy of attendance, certificates, and training topics to the Fresno CCL office by the POC due date.

Section Cited

General Food Service Requirements


	Deficient Practice Statement
1 2 3 4	Amended
	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: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/17/2022 02:27 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: ATWATER RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 247209209
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. 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 as evidenced by R1 missing 8 days of medication and R2 missing 2 PRN medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements section 87465 Incidential Medical and Dental Care are met to the Fresno CCL office by the POC due date.

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: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

LIC809 (FAS) - (06/04)

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