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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206729
Report Date: 01/08/2024
Date Signed: 01/09/2024 07:53:04 AM

Document Has Been Signed on 01/09/2024 07:53 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:SPECIALIZED RESIDENTIAL CHERYL LANEFACILITY NUMBER:
547206729
ADMINISTRATOR:NORALBA MAGANAFACILITY TYPE:
735
ADDRESS:1740 CHERYL LNTELEPHONE:
(559) 686-2593
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 6CENSUS: 6DATE:
01/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Nora Magana, Administrator TIME COMPLETED:
05:00 PM
NARRATIVE
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On 01/08/24, Licensing Program Analysts (LPA) L. Salazar and S. Hurt arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPAs were greeted by Direct Care Staff , stated the purpose of the visit and were allowed entry into the facility.

Administrator provided a tour of the facility inside and out. LPAs observed 2 residents in care at the time of visit. Facility is a 7 bedroom / 3 bathroom home. 4 out of 6 residents bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. 2 out of the 4 residents do not have all furnishings due to behaviors, which is stated in the Individual Performance Plan (IPP). Facility temperature was 70 degrees F.

Bathrooms were toured and observed to have operational lights and running water. 2 out of the 3 bathrooms have tile floor and walk in showers. A non-skid mat is not observed. Hot water temperature tested at 109 degrees F. Trash can with lid and hand washing postings were observed.

Medications were observed to be locked in a cabinet located in the kitchen. Cleaning supplies were observed to be locked in a closet in the hallway. Sharps are locked under the kitchen sink. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. There are no residents with Restricted Health conditions in the facility. There are 3 residents with special diets.

Carbon monoxide and smoke detectors were tested and observed to be operational. Fire Extinguisher was observed with a service date of 11/03/23. First aid kit was observed and contained all required items. Internet devices and a working phone line were observed to be available for residents in care.

The exterior tour of back yard was conducted and found to be free from debris. A covered outdoor seating area was observed for residents in care. Side gate was self-closing and self-latching.

(Continued on LIC 809-C)
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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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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: SPECIALIZED RESIDENTIAL CHERYL LANE
FACILITY NUMBER: 547206729
VISIT DATE: 01/08/2024
NARRATIVE
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(Continued from 809)

Residents’ files were reviewed and observed to have update emergency contacts, Admission agreement, and current physician report/individual performance plans (IPP). A sample of staff files were also reviewed. Staff files were observed to have current First Aid/CPR. Staff are fingerprinted clear and associated to the facility. 2 out of 5 staff have expired CPI training.

Quarterly Emergency Disaster Drill logs were observed for staff. LPA observed the LIC 610D (Emergency Disaster Plan) posted in the office/common area.

Based on the LPAs observations, and per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiencies are being cited on the attached 809-D.

An exit interview was conducted with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator. A plan of correction was developed with a due date of 01/22/24. A copy of this report and appeal rights were discussed and provided at the time of visit.

The following documents are requested and submitted to Fresno CCL by: 01//24:


LIC 308, LIC309, LIC 400, LIC 402, LIC 500, LIC 9020 LIC 610D,
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2024 07:53 AM - It Cannot Be Edited


Created By: Lisa Salazar On 01/08/2024 at 05:08 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: SPECIALIZED RESIDENTIAL CHERYL LANE
FACILITY NUMBER: 547206729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2024

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
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4
Based on LPA's observation during facility tour, the licensee did not comply with the section, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator will clean and repair all items given to facility by POC date. Administrator will send proof of correction by way of pictures.
Type B
Section Cited
CCR
80076(a)(6)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (6) Modified diets prescribed by a client's physician as a medical necessity shall be provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation of IPP's and current menu posted, the licensee did not comply with the section cited above in 2 out of 6 residents in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator will have special diet menus prepared according to the individual performance plans and resident's needs. Administrator will send special diet menu via email to LPA by 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 01/09/2024 07:53 AM - It Cannot Be Edited


Created By: Lisa Salazar On 01/08/2024 at 05:08 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: SPECIALIZED RESIDENTIAL CHERYL LANE
FACILITY NUMBER: 547206729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation of record reviews, the licensee did not comply with the section cited above in 1 out 6 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator will schedule an appointment for R1 to obtain a current updated LIC 602a by POC date. Administrator will send updated LIC602 when complete.
Section Cited
Emergency Intervention Staff Training
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024


LIC809 (FAS) - (06/04)
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