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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208818
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:11:50 PM

Document Has Been Signed on 02/01/2023 04:11 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:RIVERSIDE SENIOR CAREHOMEFACILITY NUMBER:
107208818
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:7435 N RIVERSIDE DRIVETELEPHONE:
(559) 412-8684
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 6DATE:
02/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Arlene BautistaTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted a Case Management - Deficiencies in conjunction with the facility Annual - Infection Control Inspection. LPA met with Administrator (AD) Arlene Bautista and Lisa Pua.


During the visit, LPA toured the facility and observed the following:
1. Resident (R1) has personal over the counter medications at bedside
2. Cleaning and Disinfecting supplies were stored in cabinets which were not locked

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D.










An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Arlene Bautista, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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 02/01/2023 04:11 PM - It Cannot Be Edited


Created By: Katie Brown On 02/01/2023 at 03:04 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: RIVERSIDE SENIOR CAREHOME
FACILITY NUMBER: 107208818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2023
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care (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 was not met as evidenced by:
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AD explained to R1 and removed the medications from the room.

During the visit AD faxed R1's Physician requesting that R1 can centrally store OTC medications. If physician agrees, the medications will be stored in a lock box in R1's room and Physician Report updated.
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Licensee did not ensure that that all medications were centrally stored and locked, inaccessible to residents. LPA observed over the counter (otc) medications on the dresser and bedside table of R1.

This poses an immediate health, safety or presonal rights risk to persons in care.
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Additionally, R1's plan of care will be updated and staff training conducted. A copy of the updated care plan and staff training will be submitted to CCLD via email by 2/9/23.
Type A
02/02/2023
Section Cited
CCR87309(a)

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87309 Storage Space (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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement was not met as evidenced by:
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AD immediately removed all disinfectants and cleaning solutions and placed them in a locked and secure cabinet.

During the visit, AD scheduled the facility maintenance agency to come to the facility 2/2/23 to place or repair locks. Pictures will be submitted to CCLD via email by 2/9/23.
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Licensee did not ensure that disinfectants and cleaning solutions were inaccessible to residents and locked. LPA observed cleaning solutions were stored in the laundry room cabinet and closet as well as in a bathroom under sinks.

This poses an immediate health, safety or personal rights risk to persons in care.
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
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