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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209313
Report Date: 03/05/2024
Date Signed: 03/05/2024 10:23:02 PM

Document Has Been Signed on 03/05/2024 10:23 PM - 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:BJ'S RESIDENTIAL, INC.FACILITY NUMBER:
247209313
ADMINISTRATOR:COWARD, BARBARAFACILITY TYPE:
735
ADDRESS:263 ELM AVETELEPHONE:
(209) 504-3817
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 6CENSUS: 6DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Barbara CowardTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee Barbara Coward, Continual Administrator's Certification expires 12/06/2024. There are currently 6 residents who currently reside in this facility. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, 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.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 100 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA Hurt reviewed personnel records for two facility staff. LPA Hurt reviewed three facility resident records. LPA Hurt confirmed all facility staff is background cleared. LPA Hurt observed client Centrally Stored Medication Logs are not updated.

There following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D 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 Licensee, Barbara Coward and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2024
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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Document Has Been Signed on 03/05/2024 10:23 PM - It Cannot Be Edited


Created By: Sarah Hurt On 03/05/2024 at 02:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: BJ'S RESIDENTIAL, INC.
FACILITY NUMBER: 247209313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)
Health-Related Services
(k) 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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Based on record review, the licensee did not comply with the section cited above in the facility does not have Centrally Stored Medication Records current and updated which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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Licensee will send current updated Centrally Stored Log to LPA Hurt by POC date of 03/06/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2024 10:23 PM - It Cannot Be Edited


Created By: Sarah Hurt On 03/05/2024 at 02:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BJ'S RESIDENTIAL, INC.
FACILITY NUMBER: 247209313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
8088(a)(1)

80088 Furniture, Fixtures, Equipment, and Supplies


(a) A comfortable temperature for clients shall be maintained at all areas.


(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. the licensee did not comply with the section cited above in LPA measured water temperature at 100 degrees,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Licensee will send proof of water temperature being between 105 and 120 degrees by POC date of 03/29/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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