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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201038
Report Date: 08/09/2023
Date Signed: 08/09/2023 11:14:19 AM

Document Has Been Signed on 08/09/2023 11:14 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: 4DATE:
08/09/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Licensee, Larry NewellTIME COMPLETED:
11:24 AM
NARRATIVE
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On 08/09/2023, Licensing Program Analysts Walton and Flores arrived unannounced to conduct a case management - annual continuation inspection. LPAs introduced themselves, stated the purpose of the visit and were granted entry to the facility. Facility staff contacted Administrator, Luz Newell-Parangalan, who arrived a short time later.

During today's visit LPAs reviewed resident medications and personnel records.

Upon entry to the facility, LPAs observed medication, that had been pre-poured into a dispensing cup, placed on the table near a R1. The medication was meant for R2. Per facility staff, R2 "was on the way" to the dining table. Review of medication revealed that the facility has been administering over-the-counter medication to residents in care. Administrator was unable to provide a physician's order prescribing the medications to residents.

Review of personnel files revealed that staff have not received annual training.

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

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Luz Newell-Parangalan, whose signature on this form confirms receipt of these documents.

LPAs are requesting the following documents be submitted to the Fresno CCL office by 08/23/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E ) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond**
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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Document Has Been Signed on 08/09/2023 11:14 AM - It Cannot Be Edited


Created By: Alexandria Walton On 08/09/2023 at 10:42 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: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility did not ensure medicines were kept in safe and locked place when staff placed medication meant for R2 in a dispensing cup near R1, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Licensee agrees to submit a written statement detailing the facility's plan to ensure medications are kept locked, and inaccessible to residents in care to the Fresno CCL office by the POC due date. Licensee also agreed to train staff on section 87465 and submit training topics and attendance to the Fresno CCL office by 09/08/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/09/2023 11:14 AM - It Cannot Be Edited


Created By: Alexandria Walton On 08/09/2023 at 10:42 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: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when the facility was unable to provide documetation that annual training has been conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure facility staff have received 20 hours of annual training, to the Fresno CCL office by the POC due date.
Type B
Section Cited
CCR
87465(a)(5)(A)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when staff administered over-the-counter medication to residents in care which had not been authorized by the person's physician, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee removed over-the-counter medication and will obtain a physician's order to administer over-the-counter medications and submit proof to the Fresno CCL office by the POC due date.
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: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
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