Community Care Licensing

Document Has Been Signed on 10/17/2022 07:43 PM - It Cannot Be Edited

FACILITY NAME:	FAIRWINDS - WOODWARD PARK		FACILITY NUMBER:	107201156
ADMINISTRATOR:	VALERO, DESIREE		FACILITY TYPE:	740
ADDRESS:	9525 N FT WASHINGTON RD		TELEPHONE:	(559) 434-6444
CITY:	FRESNO	STATE: CA	ZIP CODE:	93730
CAPACITY: 270		CENSUS: 212	DATE:	10/17/2022
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Desiree Valero, Administrator		TIME COMPLETED:	08:00 PM

SUPERVISORS NAME: Melinda Hoffmann LICENSING EVALUATOR NAME: Malia Thao LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022

Link to Parent Document Below:

FACILITY NAME: FAIRWINDS - WOODWARD PARK	FACILITY NUMBER: 107201156
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/31/2022 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will submit proof of in-service training roster with an agenda to CCL by the POC due date.
	8 9 10 11 12 13 14	LPA found that on 6/5/22, R1's medication Ciprofloxacin 500 mg Tabs (Take 1 tablet orally two times daily) were given three times at the times of 8:10 AM, 5:37 PM, and 7:22 PM. On 6/7/22, the facility received new Amlodipine 5mg (Take 1 tablet orally daily) from the pharmacy some time in the evening of the day and S1 administered a dose the same evening after finding that the new medication was received and in the med room. The facility had already given the medication Amlodipine 10mg (Take 1 tablet orally daily) earlier that day at 6:30 AM. LPA found that the facility did not receive the doctor's order for the change in dosage for the medication until 6/8/22. LPA found that R1's medication bubble pack Amlodipine 10mg that was filled on 4/21/22 to be started 5/1/22 and the bubble pack Amlodipine 10 mg that was filled on 5/20/22 to be started 5/29/22 was recorded on the Centrally Stored Medication sheet and in the facility's internal digital medication administration log as given, but both bubble packs were still intact and full without any doses administered. Which poses a potential health and personal rights risk to resident in care.	8 9 10 11 12 13 14
Type B 10/31/2022 Section Cited CCR87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will submit proof of a written statement about the facility's plan to ensure timely submission of incident reports to CCL by POC due date.
	8 9 10 11 12 13 14	CCL received a faxed incident report on 6/20/22 for an incident that occurred on 6/10/22 and the facility sent an incident report to CCL on 6/23/22 for an incident that occurred on 6/7/22, which poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Melinda Hoffmann LICENSING EVALUATOR NAME: Malia Thao LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022