Community Care Licensing

Document Has Been Signed on 08/20/2024 03:32 PM - It Cannot Be Edited

FACILITY NAME:	WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3		FACILITY NUMBER:	107201578
ADMINISTRATOR/ DIRECTOR:	WHITTLE, CHERYL A		FACILITY TYPE:	740
ADDRESS:	4093 W. TERRACE AVENUE		TELEPHONE:	(559) 271-2152
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY: 6		CENSUS: 2	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:17 AM
MET WITH:	Designee Laplac "Chris" Maxie		TIME VISIT/ INSPECTION COMPLETED:	03:50 PM

SUPERVISORS NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024

Link to Parent Document Below:

FACILITY NAME: WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3	FACILITY NUMBER: 107201578
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2024

Type A

Section Cited

CCR

87309(a)

(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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the cleaning/disinfecting supply cabinet in the garage to be unlocked, rubbing alcohol, hydregen peroxide and scissors in an unlocked cabinet in the ofice and cleaning supplies under office sink.
	POC Due Date: 08/21/2024
	Plan of Correction
1 2 3 4	All of the cleaning solutions, poisons, and other items which could pose a danger to residents were immediately secured as required and a new lock was placed on the garage cabinet. DEFICIENCY CLEARED. Administrator (AD) has agreed to conduct staff in-service to all staff.

Type A

Section Cited

CCR

87465(a)(4)

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA conducted a medication audit. R1's Lorazapam cards for 3pm and 7pm contained additional pills based on the start date as recorded by staff. 3pm - 3 additional, 7pm - 5 additional pills. Additionally, there are multiple blank MAR dates where staff did not initial - unable to confirm if medication was given as ordered.
	POC Due Date: 08/21/2024
	Plan of Correction
1 2 3 4	AD has agreed to submit a written statement which will include: plan to implement proper medication assistance procedures., Additionally, staff in-service and medication closet reorganization within 30 days. The statement will be submitted to LPA via email by POC date.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024

Link to Parent Document Below:

FACILITY NAME: WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3	FACILITY NUMBER: 107201578
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2024

Type B

Section Cited

CCR

87465(c)(3)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. The facility does not maintain a PRN log which contains all elements required in documentation.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	AD has agreed to implement the use of a PRN Log which meets the documentation requirements. Staff will be trained on the procedure. A complete training log including staff name and signature will be submitted as well as a copy of the new procedure and the log by POC date. The POC will be emailed to LPA.

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. R1's Physician Report dated 5/2023 does not document Diabetes or R1's ability to selfn administer glucose testing with assistance. Additionally, R1 and R2's reports note MCI which required to be updated allually.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	AD agrees to obtain an updated and complete Physician's Report for R1 and R2. A copy of the reports will be submitted to CCL by POC date via email.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024

Link to Parent Document Below:

FACILITY NAME: WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3	FACILITY NUMBER: 107201578
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2024

Type B

Section Cited

CCR

87465(h)(6)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. A current and complete Centrally Stored Medication and Destruction Log is not maintained.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	AD agrees to implement the use of a Centrally Stored Medication and Destruction Log. Staff will be in-serviced on the procedure and a complete sign in sheet containing names and signatures along with a copy of the updated procedure will be submitted via email to CCL by POC date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024

FACILITY NAME: WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3	FACILITY NUMBER: 107201578
	VISIT DATE: 08/20/2024