157202411-2-6-2023-24-AS-MYAG-CNSRGY-20230206120132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157202411
Report Date: 02/06/2023
Date Signed: 02/06/2023 12:02:22 PM

Document Has Been Signed on 02/06/2023 12:02 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	BLUE PEARL HOME CARE II		FACILITY NUMBER:	157202411
ADMINISTRATOR:	PINO, JELYN		FACILITY TYPE:	740
ADDRESS:	10018 SAINT ALBANS AVENUE		TELEPHONE:	(661) 412-8164
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	6	CENSUS: 6	DATE:	02/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:24 AM
MET WITH:	Petro Crisostomo, Licensee		TIME COMPLETED:	12:15 PM

NARRATIVE

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On 2/6/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Macecilia “Marie” Pasturan, Caregiver. Licensee Petro Crisostomo was called and arrived shortly and conduct tour with LPA. All five residents were present during the inspection.

Upon entry facility staff and visitors was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed.

LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage. LPA observed fire extinguisher served date: 01/24 /23. LPA observed 30 days PPE supplies. At 10:48AM, LPA and Licensee observed knives stored in drawers unlocked. At 10-:58AM, LPA and Licensee observed laundry detergent stored in unlocked cabinet in laundry room. At 11:02 AM, LPA and Licensee observed paint cans and bug spray in garage unlocked. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 2 shared residents’ bed to be at least 6 feet apart and 2 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks.

The exterior tour was conducted and observed free of obstruction and debris. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information. The required infection control practices are found to be in compliance.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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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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: BLUE PEARL HOME CARE II	FACILITY NUMBER: 157202411
	VISIT DATE: 02/06/2023

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LPA discussed past due fee with Administrator during today's inspection.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 2/17/23. The following updated forms were requested: Lic 308, Lic 500, and Lic 610E. LPA received a copy of current liability insurance and facility sketch. A copy of this report and appeal rights was provided to Licensee.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/06/2023 12:02 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: BLUE PEARL HOME CARE II	FACILITY NUMBER: 157202411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(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	Based on observation, the licensee did not comply with the section cited above when LPA and Licensee observed knives stored in drawer unlocked, two laundry detergent stored in unlocked cabinet in laundry room, and multiple paint cans next to a bottle of bug spray in garage unlocked. The knives and chemicals were unlocked and accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/07/2023
	Plan of Correction
1 2 3 4	Licensee immediately locked the shelf where knives were stored and removed chemcials into locked shelf. POC cleared during visit.

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: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/06/2023 12:02 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: BLUE PEARL HOME CARE II	FACILITY NUMBER: 157202411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87156(a)

An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185…(a)An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	The facility annual fee is overdue with a past due amount of $1,237.00. This is poses potential health and safety risk to residents in care.
	POC Due Date: 02/20/2023
	Plan of Correction
1 2 3 4	Licensee shall provide documents of annual fees have been renewed to CCL by due date 2/20/23.

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: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

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