540405657-5-4-2022-24-AS-MYAG-CE4NHM-20220504102900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 540405657
Report Date: 05/04/2022
Date Signed: 05/04/2022 10:29:08 AM

Document Has Been Signed on 05/04/2022 10:29 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	CASA GRANDE SENIOR CARE HOME #2		FACILITY NUMBER:	540405657
ADMINISTRATOR:	SILVEIRA, JOE & MARIA		FACILITY TYPE:	740
ADDRESS:	417 E. WALNUT AVE		TELEPHONE:	(559) 733-0233
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	46	CENSUS: 24	DATE:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Administrator Joe Silveira Jr. and Administrator #2 Lisa Silveira		TIME COMPLETED:	10:45 AM

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On 5/4/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Administrator Joe Silveira Jr.. Administrator #2 Lisa Silveira arrived shortly and conduct tour with LPA. All 23 residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings.

All resident’s room toured and observed to be adequately furnished and lit. All resident’s bedrooms are single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. LPA checked residents’ locked medications. LPA observed small amount of PPE supplies in facility. LPA observed 30 days PPE supplies storage in a central location. Food supply was checked and appeared to be an adequate supply. LPA and Administrator observed cleaning chemicals stored in unlocked shower room. LPA observed fire extinguisher served date: 01/04/22.

The exterior tour was conducted. Outside is free of obstruction. Staff records were reviewed for good health and infection control training. A sample of resident records reviewed to have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 5/10/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, and Lic 9020. LPA received copy of current Administrator certificate. A copy of this report and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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 05/04/2022 10:29 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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CASA GRANDE SENIOR CARE HOME #2	FACILITY NUMBER: 540405657
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 when LPA and Administrator observed cleaning chemicals on a cleaning cart stored inside an unlocked shower room. Shower room was unlocked when a resident was walking pass the shower room. Cleaning chemicals were stored and unlocked in shower room accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2022
	Plan of Correction
1 2 3 4	Licensee immediately locked the shower room door. POC cleared during visit

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: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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