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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100408901
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:59:10 PM

Document Has Been Signed on 10/14/2021 03:59 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:GARDEN MANORFACILITY NUMBER:
100408901
ADMINISTRATOR:BLACK, JOANFACILITY TYPE:
740
ADDRESS:4983 E. OLIVETELEPHONE:
(559) 255-8650
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 49CENSUS: 49DATE:
10/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Administrator, Joan BlackTIME COMPLETED:
12:53 PM
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On 10/14/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct a Case Management- Deficiencies visit. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Administrator, Joan Black.

During the course of complaint investigation # 24-AS-20210818085701, it was found that the facility did not submit an incident report on 08/12/2021 and 08/13/2021 when R1 had a witnessed fall. The Fresno CCL office was also not notified on 08/12/2021 that R1 sustained 1st and 2nd degree burns as a result of falling on asphalt.

The investigation also revealed that S3 has a conditional exemption stating S3 cannot be left unsupervised and S3’s exemption is valid for a position as a cook/kitchen help. Staff interviews revealed that S3 resides at the above facility in a unit with other residents. S3 also assists in providing care which includes assisting residents with showers, activities, and transportation.

Based on interviews and review of records, deficiencies are being cited in accordance with California Code of Regulations, Title 22, see attached LIC809D.

An exit interview was conducted and the Plans of Corrections were reviewed and developed with Administrator. As a COVID-19 precautionary measure, a copy of this signed report and appeal rights will be provided via email and an electronic read receipt confirms receiving these documents.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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 2
Document Has Been Signed on 10/14/2021 03:59 PM - It Cannot Be Edited


Created By: Alexandria Walton On 10/14/2021 at 12:55 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: GARDEN MANOR
FACILITY NUMBER: 100408901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
87356(i)

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87356(i) Criminal Record Exemption: The Department has the authority to grant a criminal record exemption that places conditions on the individual's continued licensure, and employment or presence in a licensed facility. This requirement was not met as evidenced by:
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Licensee agrees to provide written acknowledgement that S1 will not be left unsupervised with residents and a plan detailing how facility plans to ensure that S1 will not be left alone with residents by 10/15/2021.
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S1 was granted a criminal record exemption to work at this facility under the condition that S1 would not be left unsupervised with residents in care. During the course of the investigation, it was reported that S1 resides at the facility and provides unsupervised assistance to residents with showering, activities, and transportation. Which poses an immediate health and safety risk to persons in care.
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Type B
11/15/2021
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements (a) (1)): A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events. This requirement was not met as evidenced by:
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Licensee agrees to submit a plan detailing the steps the facility will take to meet the requirements of 87211 Reporting Requirements to the Fresno CCL office by 11/15/2021
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On 08/12/2021 and 08/13/2021, the facility did not submit an incident report to the Fresno CCL office when R1 had witnessed falls and on 08/12/2021 when R1 sustained 1st and 2nd degree burns. Which poses a potential health and safety risk to persons in care.
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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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
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