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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202228
Report Date: 04/27/2022
Date Signed: 04/27/2022 05:20:07 PM

Document Has Been Signed on 04/27/2022 05:20 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PLATINUM CAREFACILITY NUMBER:
275202228
ADMINISTRATOR:MILA GREENFACILITY TYPE:
735
ADDRESS:1430 COUGAR DRIVETELEPHONE:
(831) 229-0522
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY: 6CENSUS: 4DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:37 PM
MET WITH:Staff Robert Pasqual TIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Staff Robert Pasqual and discussed the purpose of the visit. LPA and Staff Robert Pasqual began the tour at the front entrance/office of the facility. LPA spoke to Administrator Mila Green via phone who gave permission for Staff Robert Pasqual to sign for this report. Administrator Mila Green assisted with visit via phone and will submit mitigation plan LIC 808 and staff training on infection control by a week from today's date. Facility will submit a photo of covered trash cans in bathrooms.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food however did not observe a seven day supply of non-perishable food. Cleaning supplies were observed to be locked in the garage. LPA observed the following personal protective; gloves, hand sanitizer and masks. LPA observed all facility staff wearing masks.

Resident’s files have updated emergency contact information.

Refer to 809d for deficiency.

Exit interview was conducted and a copy of this report was provided
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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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Document Has Been Signed on 04/27/2022 05:20 PM - It Cannot Be Edited


Created By: Shawna Doucette On 04/27/2022 at 05:00 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: PLATINUM CARE
FACILITY NUMBER: 275202228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)

(d) The licensee shall meet the following food supply and storage requirements:

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above by not having a seven day supply of non perishable food which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2022
Plan of Correction
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Plan of Correction POC Licensee agrees to submit photo of seven day supply of non perishable foods by POC due date 5/4/22
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
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