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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208813
Report Date: 09/18/2024
Date Signed: 09/18/2024 06:40:16 PM

Document Has Been Signed on 09/18/2024 06:40 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:MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEAFACILITY NUMBER:
107208813
ADMINISTRATOR/
DIRECTOR:		DIVINA GRACE PETILFACILITY TYPE:
740
ADDRESS:292 W TRENTON AVETELEPHONE:
(559) 298-7992
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 5DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Director - Grace Divina PetilTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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On 09/18/2024, 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 Director was not present in the facility and was granted entry to the facility. Facility staff contacted Director Grace Petil, who arrived a short time later.

Facility tour conducted with Tirso. Pathways in the back of the facility were obstructed.

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

Fire extinguisher was observed with a service date of 08/29/2024 All residents’ bedrooms were observed to be with comfortable temperature. Residents’ bathroom was observed, hand washing signs posted, trash receptacles did not have lids. Medications observed to be locked in a cabinet in the kitchen. Cleaning supplies were observed to be exposed and unlocked in the laundry room and restrooms. An outdoor seating area was observed accessible residents in care. LPA reviewed Staff and Resident files. Resident files observed to have update information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/03/2024: 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 (LIC9020A)
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 13
Document Has Been Signed on 09/18/2024 06:40 PM - It Cannot Be Edited


Created By: Martin Vega On 09/18/2024 at 05:30 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: MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEA
FACILITY NUMBER: 107208813

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

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: 09/19/2024
Plan of Correction
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Director Grace Petil stated that will remove all obstructions from path ways and areas accessible to residents and keep them free from obstruction. Director stated that will send LPA M. Vega photographic proof of correction.
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

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: 09/19/2024
Plan of Correction
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Director Grace Petil stated that will have fence repaired to meet compliance, and ensure that swimming pools will be fenced and inaccessible to residence. Director will provided copy of work order that stated the job was started and completed with photograpic evidence of completed repair as well.
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: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 09/18/2024 06:40 PM - It Cannot Be Edited


Created By: Martin Vega On 09/18/2024 at 05:30 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: MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEA
FACILITY NUMBER: 107208813

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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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.
POC Due Date: 09/19/2024
Plan of Correction
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Director Grace Petil stated that will remove objects which poses an immediate health, safety or personal rights risk to persons in care. Once completed will sent photographs to LPA M, Vega.
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: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 09/18/2024 06:40 PM - It Cannot Be Edited


Created By: Martin Vega On 09/18/2024 at 05:30 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: MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEA
FACILITY NUMBER: 107208813

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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Licensee Grace stated that would implemente alarms on all the doors and Plan of correction. Once completed will send pictures to LPA M. Vega
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: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


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: MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEA
FACILITY NUMBER: 107208813
VISIT DATE: 09/18/2024
NARRATIVE
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Based on observation, Deficiencies were cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809Ds, Technical Violations and Technical Advisories.

Exit interview conducted and a plan of correction was reviewed and developed with Director. A copy of this report and appeal rights were discussed and provided to Director Grace Petil, the report was signed and copy of this report was provided to Director for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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