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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201038
Report Date: 10/07/2022
Date Signed: 10/07/2022 11:23:27 AM

Document Has Been Signed on 10/07/2022 11:23 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:NAN'S TLC HOMEFACILITY NUMBER:
107201038
ADMINISTRATOR:NEWELL-PARANGALAN, LUZFACILITY TYPE:
740
ADDRESS:6643 N. MAROA AVENUETELEPHONE:
(559) 439-2465
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 3DATE:
10/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Licensee Larry Newell
Licensee/Administrator Luz Newell-Parangalan		TIME COMPLETED:
11:45 AM
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On 10/7/22 at 8:20 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management inspection. LPA explained reason for inspection and was granted entry by staff. Licensee Larry Newell and Licensee/Administrator Luz Newell-Parangalan arrived an hour later.

LPA returned to inspect the facility for correction of deficiencies CCR 87303(a) and 87307(d)(6) issued during an annual inspection on 8/12/22.

LPA observed both baby gates were removed. LPA observed hallway and master bathroom tile shower walls and floors cleaned, sliding screen doors for both master bedroom and living room replaced, pull chain installed for exterior fire exit gate, and excess electric cords in dining room were secured.

The following deficiencies were observed:
1. S1 did not have a completed transfer of criminal record clearance. S1 was present and working. S1 has been working in the facility since 9/20/22.
2. Blender blade still in blender on counter and one steak knife observed in kitchen sink and accessible.
3. Excess furniture, medical equipment, and miscellaneous items observed stored in area outside on the north side of the facility and also in the garage.

Deficiencies are being cited based on LPA observations, interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days, for a total of $500. See LIC421BG for more details.

Exit interview conducted and Plan of Corrections were reviewed and developed with Administrator Luz Newell. A copy of this report and appeal rights were given to Administrator Luz Newell, whose signature confirms receipt of this report.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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 3
Document Has Been Signed on 10/07/2022 11:23 AM - It Cannot Be Edited


Created By: Malia Thao On 10/07/2022 at 10:30 AM
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: NAN'S TLC HOME
FACILITY NUMBER: 107201038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2022
Section Cited
CCR
87533(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
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Licensee removed S1 from the facility. Licensee will submit written statement that the facility will not have staff work in the facility until the LIC9182, LIC508, and copy of proper ID is submitted to CCL and confirms completion of criminal record clearance or transfer of criminal record clearance is completed on Guardian website, to CCL by POC due date.
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S1 did not have a completed transfer of criminal record clearance, S1 was present and working, S1 has been working in the facility since 9/20/22, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
10/07/2022
Section Cited
CCR87309(a)

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87309 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:

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Licensee immediately removed and made blender with blades and steak knife inaccessible. POC cleared during inspection.
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Blender blade observed still in blender on counter and one steak knife observed in kitchen sink and accessible, which poses an immediate safety or personal rights risk to residents 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:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2022 11:23 AM - It Cannot Be Edited


Created By: Malia Thao On 10/07/2022 at 10:38 AM
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: NAN'S TLC HOME
FACILITY NUMBER: 107201038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) 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:
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Licensee states a new lock will be installed for the door to garage so that entry from kitchen will not be accessible without a key and Licensee will remove all excess furniture, medical equipment, and miscellaneous items from area outside on north side of facility by POC due date. LPA will return for POC visit.
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Excess furniture, medical equipment, and miscellaneous items observed stored in area outside on the north side of the facility and also in the garage, which poses a potential health, safety, or personal rights risk to residents 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:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
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