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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206937
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:28:02 PM

Document Has Been Signed on 09/17/2024 02:28 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BACKER SENIOR CAREHOMEFACILITY NUMBER:
107206937
ADMINISTRATOR/
DIRECTOR:		BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:9127 N BACKER AVETELEPHONE:
(559) 721-5483
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 6CENSUS: 5DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Elisa Pua - Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 09/17/2024, Licensing Program Analyst (LPA) M. Vega arrived unannounced at the above facility 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 and was granted entry to 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 except Fire Exit 4 per facility sketch. Fire Exit 4 was obstructed which presents a fire clearance issue. Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

LPA observed signs promoting hand washing, social distancing, and cough/sneeze etiquette throughout facility. LPA toured the facility kitchen. LPA observed a 30-day supply of PPE and cleaning supplies.

Fire extinguisher was observed with a service date of 09/10/2024 All residents’ bedrooms were observed to be with comfortable temperature. Residents’ bathroom was observed, hand washing signs posted, trash can have lid.

Medications observed to be locked in a cabinet in the hallway. LPA reviewed MAR; it appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the laundry room. An outdoor seating area was observed for residents in care. LPA reviewed Staff and Resident files. Resident files observed to have update information.
Continued on LIC 809C
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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 09/17/2024 02:28 PM - It Cannot Be Edited


Created By: Martin Vega On 09/17/2024 at 12:47 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: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Licensee stated that will move the waste receptacles and clear the trees covering the fire exit path.
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:Brenda Chan
LICENSING EVALUATOR NAME:Martin Vega
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BACKER SENIOR CAREHOME
FACILITY NUMBER: 107206937
VISIT DATE: 09/17/2024
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LPA is requesting the following documents be submitted to the Fresno CCL office by 10/01/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC 308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC 500), Register of Facility Clients/Residents for (LIC 9020A)

Based on observation, a deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached LIC 809D, AA informed of 24 hour POC for Deficiency, 3 Technical Violations were provided and one Technical Advisory



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, the report was signed and copy of this report was provided to Assistant Administrator for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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