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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208825
Report Date: 12/16/2024
Date Signed: 12/16/2024 09:58:00 AM

Document Has Been Signed on 12/16/2024 09:58 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:PEOPLE'S CARE DAMSENFACILITY NUMBER:
547208825
ADMINISTRATOR/
DIRECTOR:		ALBA VIAYRA, MARIANAFACILITY TYPE:
735
ADDRESS:6502 W DAMSEN AVETELEPHONE:
(559) 627-1281
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 0DATE:
12/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Administrator, Gladys HernandezTIME VISIT/
INSPECTION COMPLETED:
10:06 AM
NARRATIVE
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On 12/16/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management-deficiencies inspection. LPA contacted Director, Jose Marquez via telephone, introduced self, stated the purpose of the visit. Director gave verbal permission for LPA to meet with Administrator, Gladys Hernandez.

During the course of the investigation for Complaint #24-AS-20231221081404, the Department reviewed records and conducted interviews and found that the facility failed to seek timely medical attention for R1. R1 had a history of a chronic constipation, fecal impaction removal, and use of enemas or suppositories. Staff failed to recognize signs/symptoms (including but not limited to leaking, abdominal pain/discomfort, not eating) of possible fecal impaction and the facility did not inform R1’s PCP.

On 12/14/23 at 5:30 a.m. staff checked R1 and noted that he had mottled, darkening skin and his vitals were low. Staff did not immediately call 911, instead cleaned him up, and waited approximately 1 hour for another staff member to come to the facility to start their shift. Upon arrival to the hospital, it was determined that R1 had including but not limited to a severe fecal impaction, fractured ribs, and approximately 45 minutes after arrival to the hospital, R1 passed away.

Based on the interviews conducted and records reviewed, the resident had a change of condition beginning on 12/12/23. The resident remained in his room and was not his normal self. The resident continued to decline and no medical treatment was given until 12/14 when staff noted that the resident appeared to have darkening of the skin and low vitals.

Deficiencies are being cited in accordance with California Code of Regulations. An immediate Civil Penalty in the amount of $500 is being assessed for care and supervision. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. Exit interview conducted. A copy of this report and appeal rights were discussed and provided to Administrator, Gladys Hernandez, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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Document Has Been Signed on 12/16/2024 09:58 AM - It Cannot Be Edited


Created By: Alexandria Walton On 12/16/2024 at 09:16 AM
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: PEOPLE'S CARE DAMSEN
FACILITY NUMBER: 547208825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2024
Section Cited
CCR
80065(a)

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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs, this requirement was not met as evidenced by:
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Licensee agreed to submit a written statement detailing the steps the facility will take to ensure the requirements for section 80065 are met to the Fresno CCL office by the POC due date.
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Based on interviews and record review, the licensee failed to ensure all personnel were competent to provide services necessary to meet individual client needs, which is an immediate health and safety risk to clients in care.
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Type A
12/17/2024
Section Cited
CCR80075(a)

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Each client shall receive necessary first aid and medical or dental services, including arrangement for and/or provision of transportation to the nearest available services… this requirement was not met as evidenced by:
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Licensee agreed to submit a written statement detailing the steps the facility will take to ensure the requirements for 80075 are met to the Fresno CCL office by the POC due date.
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Based on interviews and record review, the Licensee did not ensure that R1 received medical services after R1 was observed to have a change in condition, which is an immediate health and safety risk to clients in care.
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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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
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