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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208825
Report Date: 01/13/2024
Date Signed: 01/15/2024 08:42:52 AM

Document Has Been Signed on 01/15/2024 08:42 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:ALLEN, TARAFACILITY TYPE:
735
ADDRESS:6502 W DAMSEN AVETELEPHONE:
(559) 627-1281
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 3DATE:
01/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Jose Marquez, Acting Administrator
Yadira Gamez-Plascencia, Asst Administrator		TIME COMPLETED:
06:00 PM
NARRATIVE
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On 01/13/24, Licensing Program Analyst (LPA) L, Salazar arrived to the facility unannounced to conduct the required annual inspection. LPA was greeted by Asst. Administrator/Registered Behavioral Technician (RBT), Yadira Plascencia. Current listed Administrator, Tara Allen, has recently resigned. Acting Administrator will be Jose Marquez, until Yadira Plascencia's initial Administrator certificate is issued.

LPA observed 3 residents in care at the time of visit. Facility is a 4 bedroom 3 bathroom home. Residents bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Facility temperature was 68 degrees F.

Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 117 degrees F. Trash can with lid and hand washing postings were observed.

Medications were observed to be locked in a cabinet located in the office. Cleaning supplies were observed to be locked in a supply closet located in the all. 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.

Carbon monoxide and smoke detectors were tested and observed to be operational. Night lights were observed in the hallways. Fire Extinguisher was observed with a service date of 11/16/23. 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: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2024
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: PEOPLE'S CARE DAMSEN
FACILITY NUMBER: 547208825
VISIT DATE: 01/13/2024
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(Continued from 809)

A sample of resident 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. Quarterly Emergency Disaster Drill logs were observed for staff on 11/06/23

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

An exit interview was conducted with Administrator. A plan of correction was developed with a due date of 01/22/24 and 02/12/24. 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: 02/01/24:


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: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2024 08:42 AM - It Cannot Be Edited


Created By: Lisa Salazar On 01/13/2024 at 05:32 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: PEOPLE'S CARE DAMSEN
FACILITY NUMBER: 547208825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2024

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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Based on LPA's observation during facility tour, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Administrator will complete the deep cleaning of the interior and exterior of the facility by 01/29/24 and complete the repairs/replacements by 02/12/24.
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Administrator will purchase a new mattress for Resident R1.
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: 01/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2024


LIC809 (FAS) - (06/04)
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