<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209016
Report Date: 10/28/2024
Date Signed: 11/01/2024 01:20:33 AM

Document Has Been Signed on 11/01/2024 01:20 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:LOURDES SENIOR CARE HOMEFACILITY NUMBER:
547209016
ADMINISTRATOR/
DIRECTOR:		MANCILLA, DAVILYN T.FACILITY TYPE:
740
ADDRESS:2234 E KAWEAH CTTELEPHONE:
(559) 802-3319
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 6CENSUS: 5DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Licensee/Administrator (L/A) Davilyn MancillaTIME VISIT/
INSPECTION COMPLETED:
07:00 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
An unannounced Annual visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. McClurg. LPA was greeted @ door by Caregiver 1 (CG1) Anterlyn "Lyn" Molina. LPA introduced self, stated purpose of visit, provided business card & was allowed entry. CG1 called Licensee/Administrator (L/A) Davilyn Manilla to notify that LPA was at facility. LPA spoke with L/A over phone, greeted L/A, stated purpose of visit, & inquired if L/A would be able to join LPA for visit. L/A arrived at facility afterwards & joined LPA during mid-physical plant tour. Facility does not have any bodies of water such as pool, spa, fountains, etc. Facility has a wood buring fireplace that is not in use & is blocked from view & use by large wallhanging.

When LPA entered facility, residents were observed in living area of dining room watching television. LPA greeted residents. CG1 stated that residents had just completed lunch. Caregiver 2 (CG2) Tereza Molina was at dining table eating. L/A was contacted. LPA began physical plant tour inviting CG1 to accompany L/A.

Physical plant toured. Tour began in hallway & proceeded through laundry room. Laundry appliances observed to be in use, with no laundry detergent, etc. accessible to residents. Garage accessible through laundry room. Glass cleanser observed accessible on open shelf under sink in garage. Cleanser made inaccessible @ time of visit. Over/under freezer/refrigerator labelled as "staff food". It was later determined that this appliance did contain food for resident use as well. L/A cautioned about circulating freezer items so as ice accumulation to prevent significant amount of icing to occur & to prevent freezer burn.

Resident bedrooms off of hallway toured. Bedrooms sufficiently furnished with adequate lighting. All bedrooms, including front bedroom off of facility entryway, have doors that open to backyard or side yards. Each exit door appropriately identified with Exit sign. Auditory alarms on all exit doors, including door between garage & laundry room. Auditory alarms signals in the kitchen/dining/living room area alerting staff to location of open exterior door.

Continued.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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 6
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: LOURDES SENIOR CARE HOME
FACILITY NUMBER: 547209016
VISIT DATE: 10/28/2024
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
26
27
28
29
30
31
32
Continued.

Facility has 2 bathrooms. Both bathrooms appeared to be clean with no unpleasant odors. Fixtures operational. Grab bars in toilet & shower areas. Non-skid mat in roll-in showers. Hot water measured at 110 degrees F.

Front/hallway bathroom (bath1) identified by L/A as the "staff" bathroom. Shower area used primarily by staff only, with toilet available to visitors, & occasionally by residents when toilet in bath2 is in use.
Master bathroom (bath2) off of master bedroom identified by L/A as the "resident" bathroom. Majority of toileting & all showers done in this bathroom. Access to Bath2 is through master bedroom.

Staff bedroom opposite bath1. Bedroom unlocked making contents accessible, including spray body mists, 2 bottles of room freshener liquid, eye drops, & acetone nail polish remover. Other personal items observed in clear box with locking mechanism making contents inaccessible to residents. Hazardous items made inaccessible @ time of visit.

Baseboards throughout facility in need of dusting/cleaning. All ceiling fan body & blades in need of dusting - significant accumulation of dust/fuzz observed. Air filter cover also in need of dusting/cleaning. Air filter in need of replacement. Toilet paper roll holder in need of tube mechanism.

Kitchen toured. Freezer side observed to be over-full to point of compromising circulation required. In door of refrigerator, an over half-full bottle of Pepto-Bismol observed accessible. Medication made inaccessible @ time of visit.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: LOURDES SENIOR CARE HOME
FACILITY NUMBER: 547209016
VISIT DATE: 10/28/2024
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
26
27
28
29
30
31
32
Continued.

Outside area toured. Access through sliding glass door off of dining/living room onto covered patio. Seating & table available. Backyard & side yards have rose buses. Both side yards have gates. Gate on "southwest" side of building is self-closing & self-latching. Front room egress opens directly onto this area. Other egress at back & on opposite side yard that has gate that is not self-closing & self-latching. Passageway to gate that is not self-closing/self-latching is clear & free of obstruction. This passageway is also cemented from back to front allowing steady surface for walking, walkers, & wheelchairs. "Southwest" side yard with access to gate that is self-closing/self-latching is obstructed with rose bushes & does not have a solid surface to walk on, leaving it to be muddy &/or difficult terrain to navigate with unsteady gait, walker, &/or wheelchair. Discarded mop/mop-like item observed on ground in back corner of backyard. Item removed @ time of visit. Outside yard, including front, maintained & free of any other debris.

Medications observed to be locked. Smoke detectors tested& observed to be operational. Carbon monoxide detector operational. Fire extinguisher service date: 7/2/2024.

Deficiencies issued.

Exit interview conducted with L/A. Report provided.






SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/01/2024 01:20 AM - It Cannot Be Edited


Created By: Kelly J. McClurg On 10/28/2024 at 05:41 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: LOURDES SENIOR CARE HOME
FACILITY NUMBER: 547209016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Observed accessible: Glass cleanser in garage, liquid freshener& body mist sprays in unlocked staff room;
POC Due Date: 10/28/2024
Plan of Correction
1
2
3
4
Cleared @ time of visit
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental Care
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.



This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Observed: eye drops in unlocked staff room; Pepto-Bismol in door of kitchen refrigerator
POC Due Date: 10/28/2024
Plan of Correction
1
2
3
4
Cleared @ time of visit.
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:See Moua
LICENSING EVALUATOR NAME:Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/01/2024 01:20 AM - It Cannot Be Edited


Created By: Kelly J. McClurg On 10/28/2024 at 05:41 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: LOURDES SENIOR CARE HOME
FACILITY NUMBER: 547209016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations: the following require cleaning baseboards, ceiling fan body, blades, & light fixtures; air filter cover; replace air filter; toilet paper holder missing roll holder;
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Items to be cleaned, repaired, or replaced as needed by due date.
Type B
Section Cited
CCR
87219(a)(1)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations & discussion with Licensee/Administrator, all activities are passive, i.e., watching television, movies, etc. No interactive activities provided or encouraged
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
L/A has agreed to develop a 2 week activity plan as a beginning to introduce & develop on-going interactive activities for all residents, to do as group, &/or individually during scheduled time. Plan to be submitted by due 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:See Moua
LICENSING EVALUATOR NAME:Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/01/2024 01:20 AM - It Cannot Be Edited


Created By: Kelly J. McClurg On 10/28/2024 at 05:59 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: LOURDES SENIOR CARE HOME
FACILITY NUMBER: 547209016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(C)
87307(a)(2)(C) Personal Accommodations and Services
No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with L/A, master bath being used a bathroom for all residents. Entry to master bath is through master bedroom
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
L/A has agreed to begin using hall bathroom for all residents not occupying master bedroom, to toileting, bathing, etc., immediately. L/A to submit plan that includes training by due date.
Type B
Section Cited
CCR
87555(b)(21)
87555(b)(21) General Food Service Requirements
21) Freezers… shall be kept clean and food stored to enable adequate air circulation to maintain… temperature…


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interior freezer too full to allow for adequate circulation
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
L/A has agreed to lighten capacity of freezers to allow for circulation. L/A to submit plan, including, staff training on maintaining appropriate space in appliance by due 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:See Moua
LICENSING EVALUATOR NAME:Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 6 of 6