547206566-7-30-2024-24-AS-MMEA-D7NTGZ-20240730144359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547206566
Report Date: 07/30/2024
Date Signed: 07/30/2024 02:44:30 PM

Document Has Been Signed on 07/30/2024 02:44 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:	J & M ELDERLY HOMECARE		FACILITY NUMBER:	547206566
ADMINISTRATOR:	PIRA, J. & RAFANAN, M.		FACILITY TYPE:	740
ADDRESS:	3510 W. ELOWIN AVENUE		TELEPHONE:	(559) 303-8043
CITY:	VISALIA	STATE: CA	ZIP CODE:	93291
CAPACITY:	6	CENSUS: 3	DATE:	07/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:14 PM
MET WITH:	Jose Pira		TIME COMPLETED:	03:05 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 7/30/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, and allowed entrance by Direct Care Staff. Administrator, Jose Pira contacted by telephone and arrived a short time later to conduct annual inspection.

Facility tour conducted, facility observed to be well lit, a comfortable temperature and odor free. All common areas observed to have adequate seating for residents in care. Resident bedrooms observed to have all required furnishings, residents observed to be relaxing watching television at time of inspection. Resident bathroom toured, LPA observed grab bars, shower chair, and non-skid mats available. Water temperature measured at 111 degrees F. Kitchen toured, LPA observed adequate food supply for residents in care. Knives observed to be locked and secured in kitchen drawer. All medications observed to be locked and secured in cabinet. Medications observed to have original labels and be administered as prescribed.

Outside of facility toured. LPA observed 2 separate rooms with locking doors in the garage that are not part of facility sketch. LPA also observed an unlocked shed in the back yard containing hazardous items accessible to residents.

Deficiencies cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D.

Due to time restraints LPA will return to conduct staff and resident file reviews.

An exit interview was conducted. Plan of Correction and appeals rights given. A copy of report provided to licensee for facility records.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

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 3

Document Has Been Signed on 07/30/2024 02:44 PM - 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: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(1)

Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: LPA observed storage shed in the backyard containing hazardous items to be unlocked and accessible to residents.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2024
	Plan of Correction
1 2 3 4	Licensee to purchase locks and secure all hazardous items inside the storage shed.

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) 341-3247
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/30/2024 02:44 PM - 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: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: LPA observed 2 separate rooms with locking doors in the garage that are not part of facility sketch
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	Licensee to write a statement to department acknowleding understanding of regulation and consult with City of Visalia regarding additional rooms built without permits. Licensee to also submit updated facility sketch to include addition.

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) 341-3247
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3