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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208818
Report Date: 02/21/2024
Date Signed: 02/21/2024 04:50:47 PM

Document Has Been Signed on 02/21/2024 04:50 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: 5DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Arlene BautistaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Arlene Bautista and Assistant Administrator Elisa Pua.

During this visit, LPA toured the facility inside & out. Resident bedrooms are found in good repair, contained required furnishings and lighting. The resident bathrooms were clean and in good repair with faucets delivering hot water. LPA observed required hygiene items and grab bars. Towels, extra bedding, and linens were stored and available for use. The kitchen was clean, in good repair with necessary items and appliances. LPA observed required food supply, PPE and paper product storage. Knives/sharps, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored in a locked cabinet. A First aid kit contained required items. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. LPA observed a self-releasing gate and windows have screens in good repair. Smoke and Carbon Monoxide detectors were tested during the visit. The Fire extinguishers were purchased 5/12/23. LPA conducted resident and staff file reviews including medication audit.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.



An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 3/6/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Emergency Disaster Plan (LIC610E), Personnel Report (LIC 500). Client Roster (LIC 9020), Proof of current Liability Coverage, Infection Control Plan

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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 8
Document Has Been Signed on 02/21/2024 04:50 PM - It Cannot Be Edited


Created By: Katie Brown On 02/21/2024 at 03:47 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: RIVERSIDE SENIOR CAREHOME
FACILITY NUMBER: 107208818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.39(b)
Regulations
(b) A residential care facility for the elderly that accepts or retains residents with restricted health conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals acting within their scope of practice. An appropriately skilled professional may not be required when the resident is providing self-care, as defined by the department, and there is documentation in the resident’s service plan that the resident is capable of providing self-care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. R1's service plan does not address Diabetes Management, staff assistance or Stage 2 wound care, R2 was assisted with Humalog incections of the wrong dose, service plan does not adress Oxygen use or Diabetic management
POC Due Date: 02/22/2024
Plan of Correction
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AD has agreed to conduct Insulin injection assistance training to staff today. Training will include include hand over hand technique, sliding scale dose determination and documentation. A statement of completion with training description and documentation of physician communication will be provided to CCLD by POC date via email. Additionally, resident service plans will be updated to include restricted conditions management. Proof of training and plans will be submitted to CCLD by 3/6/24 via email.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 02/21/2024 04:50 PM - It Cannot Be Edited


Created By: Katie Brown On 02/21/2024 at 03:47 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: RIVERSIDE SENIOR CAREHOME
FACILITY NUMBER: 107208818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(A)2
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (A) Identification of a staff position to perform the duties of an Infection Control Lead for the facility. 2. A description shall be included of how the Infection Control Lead shall be trained by a medical professional, local health official, health department, or other research-based medical authority that provides infection control training that will include enforcement of the Infection Control Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. The identified Infection Control Lead has not received the required training.
POC Due Date: 03/06/2024
Plan of Correction
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AD has agreed to obtain the required Infection Control Training and conduct annual training to all staff as required. AD will provide proof of completed training to CCLD by POC date via email.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. The facility did not assess R3 prior to return from a hospital stay resulting in R3 returning with a cathater. Facility was not aware of the change of condition and cathater.
POC Due Date: 03/06/2024
Plan of Correction
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AD has agreed to revise the procedure for assessing a resident after hospitalization. A copy of the revised procedure will be provided to CCLD by the POC date via email.
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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/21/2024 04:50 PM - It Cannot Be Edited


Created By: Katie Brown On 02/21/2024 at 03:47 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: RIVERSIDE SENIOR CAREHOME
FACILITY NUMBER: 107208818

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87609(b)(4)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. R1 and R3 are currently receiving services from Home Health Agencies. The facility does not have a written agreement or communication log of services being provided for either.
POC Due Date: 03/06/2024
Plan of Correction
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AD has agreed to create and implement a written agreement for Home Health Agencies providing care to residents. A copy of signed agreements for R1 and R3 will be provided to CCLD by the POC date via email.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
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