Routine inspection·February 23, 2022

Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. Administrator Elizabeth Perera was unavailable and designated Virginia Jimenez, Manager to meet with LPA. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the kitchen sink. Bedrooms were checked. The exterior tour was conducted. LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. On 02/09/2022, CCL received a Special Incident (SIR) Report Central Valley Regional Center regarding incident that occurred on 10/29/2021. As of today’s, date, CCL did not receive an SIR from the facility of the 10/29/2021 incident. Per SIR, Client (C1) was in the dining room area went up to C2 to hug him. C2 moved his hands and C1 grabbed C2’s wheelchair. C2 became upset and grabbed C1’s wheelchair and threw him down. When C1 was on the floor, C2 hit C1 on the face. LPA requested further documents regarding the 10/29/2021 and 11/03/2021 incidents. LPA will return to facility to address any concerns after records are reviewed. Deficiencies are being cited on the attached LIC 809-D. Exit interview was conducted. A copy of this report, LIC809, LIC809-D and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): · LIC 308 Designation of Facility Responsibility · -as applicable: LIC 309 Administrative Organization · -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources · -as applicable: LIC 402 Surety Bond · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly · LIC 9020 Register of Facility Clients/Residents · Copy of current Liability Insurance · Copy of current Administrator Certificate · Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 03/02/2022 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.