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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
275202839
Report Date:
01/24/2024
Date Signed:
01/24/2024 03:06:55 PM
Document Has Been Signed on
01/24/2024 03:06 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:
HARTNELL HOME ONE
FACILITY NUMBER:
275202839
ADMINISTRATOR:
BINARAO, PATRICK
FACILITY TYPE:
735
ADDRESS:
618 HARTNELL ST.
TELEPHONE:
(415) 336-5277
CITY:
SALINAS
STATE:
CA
ZIP CODE:
93901
CAPACITY:
6
CENSUS:
4
DATE:
01/24/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:15 PM
MET WITH:
Facility staff Igmedio Chavez
TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sarah Hurt, and Lisa Salazar conducted an unannounced visit today for the facility’s annual inspection. LPA met with Facility staff Igmedio Chavez Continual Administrator's Certification for Nicholas Binarao expires 12/09/2024. There are currently 4 residents who reside at this home. The facility has 6 staff living in this facility, and 4 bedrooms dedicated for staff use. 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. There is a locked storage for medications.
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. Facility has current Emergency Disaster plan. Toxins and cleaning supplies are locked and inaccessible.
Water temperature was tested at 121 degrees. LPA's observed the hallway toilet is in disrepair. LPA's observed several holes in facility walls. LPA's observed a shared towel in hallway bathroom. LPA's observed a dirty, and what appears to be moldy window frame in resident bedroom. LPA's observed a rusty mirrored cabinet in facility hallway bathroom, LPA's observed Resident 1's mattresses to be in disrepair (springs not in good repair.) LPA's observed facility hallway light fixture with no covering. LPA's observed resident bedrooms do not have required lamp or personal lighting. LPA's observed facility hallway bathroom cabinet lock to be broken and hanging off the door. LPA's observed facility kitchen area around the stove (stove hood), and kitchen walls, ceiling, and cabinets to be dirty. LPA's observed facility hallway bathroom temperature to measure at 121 degrees. LPA's observed facility temperature to be below the required minimum of 68 degrees. LPA's observed facility gutters are in need of cleaning and a section of gutter on the southwest side of the home in need of repair.
Continued...
SUPERVISORS NAME
:
Brenda Chan
LICENSING EVALUATOR NAME
:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/24/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/24/2024
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
5
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:
HARTNELL HOME ONE
FACILITY NUMBER:
275202839
VISIT DATE:
01/24/2024
NARRATIVE
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Continued..
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 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, Ignedio Chavez and copy of report left at facility
SUPERVISORS NAME
:
Brenda Chan
LICENSING EVALUATOR NAME
:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/24/2024
LIC809
(FAS) - (06/04)
Page:
5
of
5
Document Has Been Signed on
01/24/2024 03:06 PM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
01/24/2024
at
02:21 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:
HARTNELL HOME ONE
FACILITY NUMBER:
275202839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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 LPA's observed several holes in facility walls. LPA's observed a dirty, and what appears to be moldy window frame in resident bedroom. LPA's observed a rusty mirrored cabinet in facility hallway bathroom, LPA's observed facility hallway light fixture with no covering, facility hallway bathroom cabinet lock to be broken and hanging off the door, facility kitchen area around the stove (stove hood), and kitchen walls, ceiling, and cabinets to be dirty, facility gutters are in need of cleaning and a section of gutter on the southwest side of the home in need of repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/01/2024
Plan of Correction
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3
4
Administrator will clean necessary areas, make required repairs, and send proof to LPA'S by POC date of 02/01/2024.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in facility hallway toilet is in disrepair (lid cover broken) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/01/2024
Plan of Correction
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2
3
4
Administrator agrees to repair front hallway facility toilet and send proof to LPA by POC date of 02/02/2024.
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
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
01/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/24/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
01/24/2024 03:06 PM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
01/24/2024
at
02:21 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:
HARTNELL HOME ONE
FACILITY NUMBER:
275202839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).
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 Resident 1's mattress springs are not in good repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/01/2024
Plan of Correction
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4
Administrator agrees to replace matress for Resident 1 by 02/01/2024 POC date.
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.
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 Resident bedrooms do not have required lamp or necessary personal lighting, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/01/2024
Plan of Correction
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2
3
4
Administrator agrees to provide necessary required necessary personal lighting for residents, and submit proof to LPA's by 02/01/2024 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
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
01/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/24/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
01/24/2024 03:06 PM
- It Cannot Be Edited
Created By:
Sarah Hurt
On
01/24/2024
at
02:42 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:
HARTNELL HOME ONE
FACILITY NUMBER:
275202839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
8088(a)(1)(C)
80088 Furniture, Fixtures, Equipment, and Supplies
(a) A comfortable temperature for clients shall be maintained at all areas.
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).
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 facility room temperature is below required minimum 68 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/01/2024
Plan of Correction
1
2
3
4
Administrator agrees to ensure facility room temperature does not go below required minimum of 68 degrees,and send proof to LPA by POC date of 02/01/24.
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
LICENSING EVALUATOR NAME:
Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE:
01/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/24/2024
LIC809
(FAS) - (06/04)
Page:
4
of
5