Community Care Licensing

Document Has Been Signed on 08/28/2024 10:06 AM - It Cannot Be Edited

FACILITY NAME:	MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO		FACILITY NUMBER:	107208807
ADMINISTRATOR/ DIRECTOR:	BRICE, NASTASSHA		FACILITY TYPE:	740
ADDRESS:	149 OAK AVENUE		TELEPHONE:	(559) 765-4287
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY: 6		CENSUS: 6	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Administrator MaDivina “Grace” Petil		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

SUPERVISORS NAME: See Moua LICENSING EVALUATOR NAME: Mai Yang LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024

Link to Parent Document Below:

FACILITY NAME: MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO	FACILITY NUMBER: 107208807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

Type A

Section Cited

CCR

87355(e)(2)

87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed S1 working with residents. S1 is fingerprinted cleared and is not associated to facility which poses an immediate risk to the health and safety of the residents.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	S1 was immediately removed from the facility. S1 is not permitted back until associated. Licensee is to submit LIC 9182 Fingerprint transfer request to Fresno CCL office by POC due date 08/27/24.

Type A

Section Cited

CCR

87405(d)(2)

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Fire Extinguisher was observed with a service date of 07/20/22, which poses an immediate health and safety risk to the residents.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Fire extinguisher shall be replaced or serviced with a current date. Proof of correction will be submitted to the Fresno CCL office by POC due date 08/27/24.

SUPERVISOR'S NAME: See Moua LICENSING EVALUATOR NAME: Mai Yang LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024

Link to Parent Document Below:

FACILITY NAME: MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO	FACILITY NUMBER: 107208807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

Type A

Section Cited

CCR

87458(b)(1)

87458(b)(1) 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 records reviewed, 2 out of 6 residents do not have TB result on file which poses a immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Licensee to schedule doctor’s appointment to complete TB testing for R1 and R2. Scheduled time of appointment shall be submitted to CCLD by due date 08/27/24. TB result for R1 and R2 shall be submitted to Fresno CCL by POC due date 9/16/24.

Type A

Section Cited

HSC

1569.618(c)(3)

1569.618 (c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	S2 working on shift do not have current First Aid/ CPR certification, this poses an immediately health and safety risk for the residents in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure that staff have current First Aid/ CPR certification. Proof of staff First Aid/ CPR certification is to be submitted to the Fresno CCL by 08/27/24.

SUPERVISOR'S NAME: See Moua LICENSING EVALUATOR NAME: Mai Yang LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024

Link to Parent Document Below:

FACILITY NAME: MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO	FACILITY NUMBER: 107208807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

Type B

Section Cited

CCR

87303(a)(1)

87303(a)(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. 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 when LPA observed the non-skid mat and shower floor with mold in the master bathroom which poses a potential health, safety or personal rights risk to person in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	The staff immediately cleaned the shower floor and removed the mold non-skid mat. POC cleared during visit.

Type B

Section Cited

CCR

87303(e)(5)

87303(e)(5) Non-skid mats or strips shall be used in all bathtubs and showers. 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 when hall bathroom was observed with no non-skid mat or strips in the bathtub which poses a potential health, safety or personal rights risk to person in care.
	POC Due Date: 08/30/2024
	Plan of Correction
1 2 3 4	Proof of non-skid mat in the hall bathroom shall be submitted to the Fresno CCL by POC due date 08/30/24.

SUPERVISOR'S NAME: See Moua LICENSING EVALUATOR NAME: Mai Yang LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024

Link to Parent Document Below:

FACILITY NAME: MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO	FACILITY NUMBER: 107208807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

Type B

Section Cited

CCR

87638(g)(3)(A)

87638(g)(3)(A) The documentation to complete the resident's review request shall include (3) An appraisal or reappraisal of the resident (A)The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal or reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA reviewed all residents’ files and observed 5 out of 6 resident do not have an appraisal (Lic 603) and needs service plan (Lic 625) which poses a potential health, safety or personal rights risk to person in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Licensee shall complete an appraisal and needs services plan for R1, R2, R3, R4, and R5. Appraisal and Needs services plan shall be submitted to the Fresno CCL by POC due date 09/06/24.

Type B

Section Cited

CCR

87412(c)

87412(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed and interviews, no records of staff trainings on file which poses a potential health and safety risk for the person in care.
	POC Due Date: 09/22/2024
	Plan of Correction
1 2 3 4	Facility shall review regulation section 87412 and ensure that all staff have the required training. Proof of trainings is to be submitted to the Fresno CCL office by the POC due date 09/22/24. Proof of training shall include the following: Trainer’s full name and title; Subject(s) covered in the training; Date(s) of attendance; and Number of training hours per subject.

SUPERVISOR'S NAME: See Moua LICENSING EVALUATOR NAME: Mai Yang LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024