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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
247209209
Report Date:
03/27/2024
Date Signed:
04/02/2024 10:14:53 AM
Document Has Been Signed on
04/02/2024 10:14 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 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:
4
DATE:
03/27/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
Facility Staff Pamela Pinnock
TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sarah Hurt and Brianna Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility staff Pamela Pinnock, Continual Administrator's Certification for Administrator Lacy Vincent is 04/25/2024. There are currently 4 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.
Smoke alarms were tested and are operational. The home has a carbon monoxide detectors. Water temperature was tested at 129 degrees. First Aid kit is on site and is not complete. LPA's were not provided access to facility staff or client records. LPA's were not able to determine any resident diagnosis or resident needs as client records are not available. LPA's are not able to review staff training as Personnel records are not able for review. Staff 1 present was not able to provide proof of required First Aid training. Resident 1's Centrally Stored Medication log is not properly maintained, and medications are not being given due to being out. LPA's observed multiple facility window screens with tears and not in good repair. LPA's observed several expired food items in facility pantry. LPA's observed facility Resident 1 outside and needing constant supervision along with 2 other residents present. LPA's observed a sliding lock more than 6 feet high on the inside front door out of resident reach which is a potential fire clearance hazard. LPA's were not able to review facility Disaster Plan 610E or log of quarterly disaster drills.
The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.
LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file.
Listed documents shall be sent to Licensing.
Exit interview conducted with Facility Staff Pamela Pinnock and copy of report left at facility
SUPERVISOR'S NAME:
Brenda Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Sarah Hurt
TELEPHONE:
559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE:
03/27/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/27/2024
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
6
Document Has Been Signed on
04/02/2024 10:14 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
CCLD Regional Office
,
,
CA
FACILITY NAME:
ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER:
247209209
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in LPA's measured hallway bathroom water temperature to be 129 degrees, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/28/2024
Plan of Correction
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4
Licensee will lower water temperature to be within required temperature of 105 to 120 and send proof to LPA by POC date of 03/28/2024.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review the licensee did not comply with the section cited above in LPA's were not able to verify Staff 1 has required current first aid training, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/28/2024
Plan of Correction
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Licensee will send proof of Staff 1's first aid training to LPA by POC date of 03/28/2024.
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:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Sarah Hurt
TELEPHONE:
(916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE:
03/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/27/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
04/02/2024 10:14 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
CCLD Regional Office
,
,
CA
FACILITY NAME:
ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER:
247209209
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, and record review, the licensee did not comply with the section cited above in LPA's were not able to review Personnel records as they were not accessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/28/2024
Plan of Correction
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4
Licensee will provide Personnel records for all facilty Personnel to LPA by 03/28/2024 POC date.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in Resident 1 was not given Levothyroxine medication for several days due to being out of the medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/28/2024
Plan of Correction
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Licensee will send proof of medication being filled to LPA by POC date of 03/28/2024.
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:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Sarah Hurt
TELEPHONE:
(916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE:
03/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/27/2024
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
04/02/2024 10:14 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
CCLD Regional Office
,
,
CA
FACILITY NAME:
ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER:
247209209
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on records review, the licensee did not comply with the section cited above in Resident 1's medications are not currently logged on the Centrally Stored Medication Record, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/07/2024
Plan of Correction
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Licensee will provide corrected Centrally Stored Medication Log for all facilty residents, and verification to prevent this error from reoccuring,
Type A
Section Cited
CCR
87506(a)
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.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, and record review the licensee did not comply with the section cited above in LPA's were not able to review any of the 4 residents records as they were not made available, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/28/2024
Plan of Correction
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Licensee will provide records for all 4 facility residents by 03/28/2024 POC date.
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:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Sarah Hurt
TELEPHONE:
(916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE:
03/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/27/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
04/02/2024 10:14 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
CCLD Regional Office
,
,
CA
FACILITY NAME:
ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER:
247209209
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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 in LPA's observed several expired foot items in facility pantry, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
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Licensee will conduct staff training or submit a plan to prevent expired food inside facility pantry and submit proof to LPA POC date 04/11/2024.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, and record review, the licensee did not comply with the section cited above in LPA's requested and were not provided facilities 610E Disaster Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/11/2024
Plan of Correction
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2
3
4
Licensee will provide 610D Emergency Disaster Plan to LPA by POC date of 04/11/2024.
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:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Sarah Hurt
TELEPHONE:
(916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE:
03/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/27/2024
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
04/02/2024 10:14 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:
03/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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 in LPA's observed a lock on the facility front door more than 6 feet high, and not accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/28/2024
Plan of Correction
1
2
3
4
Licensee will ensure locks if not fire cleared will be removed, and send proof to LPA by POC date of 03/28/2024.
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:
Brenda Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Sarah Hurt
TELEPHONE:
559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE:
03/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/27/2024
LIC809
(FAS) - (06/04)
Page:
6
of
6