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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 09/23/2022
Date Signed: 09/26/2022 05:13:50 PM


Document Has Been Signed on 09/26/2022 05:13 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/26/2022 05:06 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 09/23/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management – deficiencies visit. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Administrator, Jessica Johnson.

The purpose of this visit is to follow up on an incident reports submitted to the Fresno CCL office.

Upon entry to the facility, LPA observed an uncleared staff working in the facility. Per ADM, S1 has worked in the facility for training yesterday, 09/22/2022 and is currently in training today 9/23/2022. LPA informed ADM that S1 is not cleared and cannot work in the facility until S1 receives fingerprint clearance and is associated to the facility.

Regarding the incident that was reported to the Fresno CCL office, Administrator (ADM) reported that on 8/28/2022, R1 left the facility after repeated attempts to redirect R1, and entered a neighboring home, resulting in ADM calling law enforcement. Additionally, R1’s personal rights were violated when ADM administered PRN medications to R1 while R1 was restrained.

Based on interviews with ADM, deficiencies are being cited in accordance with the California Code of Regulations, Title 22 , Division 6 on the attached 809D. An immediate civil penalty is being assessed in the amount of $500 for Care and Supervision on the attached LIC421IM and an immediate civil penalty in the amount of $100 is being assessed for Caregiver Background Check on the attached LIC421BG, for a total of $600.

Exit interview conducted and a Plan of Correction was reviewed and developed with ADM. A copy of this report was discussed and provided to Administrator, Jessica Johnson, whose signature on this form confirms receipt of this document

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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: 09/23/2022
NARRATIVE
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This is an amended report.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 09/26/2022 05:13 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/26/2022 05:10 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: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2022
Section Cited

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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Based on interviews, Licensee did not ensure all residents were provided care and supervision when on 08/28/2022, R1 was able to "bypass" facility staff, exit the facility, and enter a neighboring home unsupervised, which poses an immediate health and safety risk to persons in care.
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Licensee agrees to train all staff on requirements of Additional Personal Rights of Residents in Privately Operated Facilities by 10/14/2022. Evidence of training topics and attendance will be submitted to the Fresno CCL office by 10/14/2022.
Type A
09/27/2022
Section Cited

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(a) A plan for incidental medical and dental care shall be developed by each facility…. (5) Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement was not met as evidenced by:
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Based on interviews, the Licensee did not ensure that the requirements for the section 87465(a)(5)(D) on 08/28/2022 when ADM administered PRN medications to R1 while R1 was restrained. This poses an immediate health and safety risk to residents in care
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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 HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3