547206566-7-26-2023-24-AS-MTHO-CU4SM4-20230726135920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547206566
Report Date: 07/26/2023
Date Signed: 07/26/2023 01:59:34 PM

Document Has Been Signed on 07/26/2023 01:59 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
SIERRA CASCADE AC/SC, 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: 4	DATE:	07/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Jose Pira, Licensee/Administrator		TIME COMPLETED:	02:30 PM

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On 7/26/23 at 9:41 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee/Administrator (LIC) Jose "Joe" Pira arrived a short time later.

Facility was toured with ADM. Smoke and carbon monoxide detectors tested and operational. Bedrooms were checked. Centrally stored medication observed in locked kitchen cabinet. Food supply was observed in adequate supply. Cleaning supplies observed in laundry room. Hot water in hall bathroom measured at 115.4 degrees F. Staff and resident records reviewed. Administrator certification is valid.

The following deficiency was observed:
1. R1 was admitted to the facility with hospice care, on 3/1/23. Facility does not have a hospice care plan in place between the hospice agency and the facility.

Deficiency is being cited based on LPA interview and record review conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and a Plan of Correction was reviewed and developed with the Licensee. A copy of this report and appeal rights were given to Licensee, whose signature on this form confirms receipt of these documents.

The following updated forms are to be submitted to CCL within 2 weeks:

LIC610E, LIC500, LIC9020, Proof of liability insurance, LIC308

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 07/26/2023 01:59 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: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(b)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. R1 was admitted to the facility with hospice care, on 3/1/23. Facility does not have a hospice care plan in place between the hospice agency and the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of a hospice care plan for R1, to CCL by POC due date.

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) 341-3274
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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