Facility Evaluation Report

On 6/27/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Licensee Jared Sandoval. Three residents were present during inspection.

All pathways, entrances and exits were clear from obstructions. LPA and Licensee began tour at the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Dinning area observed with table and chairs. Staff room next to the dining area toured. At 2:06 PM Laundry area toured and observed to have unlocked chemicals, laundry soap and cleaning supplies. Fire extinguisher in kitchen was last serviced on 6/4/2024 and was fully charged. Tour continued to the living area which has sufficient seating. LPA toured three resident rooms upstairs which were observed to be furnished with required furniture and adequate lighting. At 2:12 PM LPA observed rug leading into bedroom was lifted and above the Transition strip. At 2:20 Master bedroom and bathroom were observed with debris on the floor; bathrooms and showers observed with stains. Master Shower observed to have black stain at the base of the wall tile. Bedrooms observed to have debris around corners and near furniture. Linen supply is kept in the Hallway closet upstairs. Hallway bathroom observed to have missing baseboard with nails sticking out. Medications are kept locked in the cabinets in the laundry room. LPA observed covered patio area. Backyard gate was self-latching and self-closing. Carbon monoxide and smoke alarm detectors installed and operational. LPA reviewed resident’s medication and Centrally Stored List for all residents. Resident's records contained signed Admission Agreement, and current Physician's Report. Staff files were reviewed and had required documents. Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 7/5/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. Appeal rights provided Report signed on-site by staff and printed copy provided.