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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206566
Report Date: 08/09/2022
Date Signed: 08/09/2022 11:14:25 AM


Document Has Been Signed on 08/09/2022 11:14 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:J & M ELDERLY HOMECAREFACILITY NUMBER:
547206566
ADMINISTRATOR:PIRA, J. & RAFANAN, M.FACILITY TYPE:
740
ADDRESS:3510 W. ELOWIN AVENUETELEPHONE:
(559) 303-8043
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:6CENSUS: 5DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Jose PiraTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst LPA Shawna Doucette and Vadim Gorban conducted an Annual Infection Inspection on this date. LPA was met by Staff and discussed the purpose of the visit. Administrator Jose Pira responded to the facility to assist with the inspection. LPA and Administrator Jose Pira began the tour at the front entrance/office of the facility.

LPA's entered the facility and observed R1 to be restrained in a wheelchair by a postural support belt. LPA's reviewed records and R1 did not have a physicians note for the restraint. While touring the facility LPA's observed a bottle of acetaminophen on the dresser in room 3 accessible to residents in care.

Facility has a mitigation plan however needs to submit the plan on an LIC808.

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. Covid-19 related signs were observed in the common areas.

Cleaning supplies were observed locked in cabinet in the garage. LPA observed the following personal protective equipment in garage; gowns, gloves, face shields, hand sanitizer and masks. LPA observed all facility staff to be wearing masks upon arrival.

Resident’s files have updated emergency contact information. LPA's reviewed staff training for Covid.

See 809D for deficiencies

Exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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 2


Document Has Been Signed on 08/09/2022 11:14 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: J & M ELDERLY HOMECARE
FACILITY NUMBER: 547206566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.

(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by having R1 restrained in R1's wheelchair without a physician's note, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Plan of Correction POC Licensee agrees to provide a written statement on the understanding of this regulation and submit a physician's note for R1 for a postural support by POC due date 8/31/22.
Type A
Section Cited
CCR
87465(2)
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 by having one bottle of acetaminophen located on the dresser in room 3 accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Licensee agrees to conduct a staff training regarding the storage of medication by 8/31/22

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 PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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