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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206937
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:48:08 PM

Document Has Been Signed on 08/03/2022 12:48 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:BACKER SENIOR CAREHOMEFACILITY NUMBER:
107206937
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:9127 N BACKER AVETELEPHONE:
(559) 721-5483
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 6CENSUS: 5DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Assistant Administrator, Elisa PuaTIME COMPLETED:
01:00 PM
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On 08/03/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff informed LPA that Administrator was not present in the facility. Facility staff contacted Assistant Administrator (AA), Elisa Pua, who arrived a short time later.

Facility tour conducted with AA. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette throughout facility. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA observed an adequate supply of food. LPA observed a 30 day supply of PPE and cleaning supplies. Hand- sanitizer is readily available.

Facility has 4 bedrooms, 2 bedrooms are single occupant and 2 bedrooms are double occupant. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs were observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply. LPA observed refrigerated medications to be accessible to residents in care in a box in the refrigerator. Resident records have updated emergency contact information. Facility staff records reviewed for good health.

LPA is requesting the following documents be submitted to the Fresno CCL office by 08/17/2022: 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.

CONTINUED TO LIC809C

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BACKER SENIOR CAREHOME
FACILITY NUMBER: 107206937
VISIT DATE: 08/03/2022
NARRATIVE
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Based on observation, a deficiency is 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 Assistant Administrator. A copy of this report and appeal rights were discussed and provided to Assistant Administrator, Lisa Pua, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/03/2022 12:48 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/03/2022 at 12:27 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: BACKER SENIOR CAREHOME
FACILITY NUMBER: 107206937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(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 licensee did not comply with the section cited above, when LPA observed medications to be in a locked box in the refrigerator accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Licensee agrees to purchase a lock box for refrigerated medications to ensure medications are inaccessible to residents in care and submit proof to the Fresno CCL office by the POC due date.
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: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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