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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208905
Report Date: 07/30/2024
Date Signed: 07/30/2024 04:33:08 PM

Document Has Been Signed on 07/30/2024 04:33 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:HEART TO HEART FAMILY CARE CENTER LLCFACILITY NUMBER:
107208905
ADMINISTRATOR/
DIRECTOR:		VANG, CHAOFACILITY TYPE:
740
ADDRESS:672 E WRENWOOD AVETELEPHONE:
(559) 797-2166
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Katie Brown and Daiquiri Boyd arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Chao Vang.

During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting. The bathrooms were found to be clean with faucets delivering hot water at 106 degrees. LPA observed required hygiene items, towels, extra bedding, and linens which were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage. Medications are locked and centrally stored in a locked hallway closet. Common and activity areas were clean and occupied by residents throughout. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were serviced April 2024 by Valley Fire Company.


Due to time constraint, LPAs were not able to complete the inspection and will return at a later date.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Storage Space, Incidental Medical and Dental Care Services, Maintenance and Operation

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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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 4
Document Has Been Signed on 07/30/2024 04:33 PM - It Cannot Be Edited


Created By: Katie Brown On 07/30/2024 at 03:32 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: HEART TO HEART FAMILY CARE CENTER LLC
FACILITY NUMBER: 107208905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

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. Licensee did not ensure cleaning supplies, laundry detergents, bug sprays were inaccessable to residents. The above were stored in the garage which was unlocked.
POC Due Date: 07/31/2024
Plan of Correction
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AD agreed to submit pictures that demonstrate the locked inaccessable storage of the above items. Pictures will be submitted by POC date via email to LPA Brown.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Licensee did not ensure that medications were given as prescribed. LPAs observed pre-filled medications in the med cabinet that staff confirmed were not given to a resident.
POC Due Date: 07/31/2024
Plan of Correction
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AD agrees to provide a written statement that the regulations have been reviewed, medication assistance procedures have been reviewed and PRN medication will not be pre-filled. This statement will be signed by staff who assist with medication assistance. The signed statement will be submitted via email by POC date to LPA.
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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/30/2024 04:33 PM - It Cannot Be Edited


Created By: Katie Brown On 07/30/2024 at 03:32 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: HEART TO HEART FAMILY CARE CENTER LLC
FACILITY NUMBER: 107208905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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. LPAs observed pre-filled medications. The med cups contained unlabled PRN and routine medications were kept in the same cup
POC Due Date: 07/31/2024
Plan of Correction
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AD agrees to submit a written statement that states that the regulation has been reviewed and understood. This written statement will be submitted to LPA via email by POC date.
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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/30/2024 04:33 PM - It Cannot Be Edited


Created By: Katie Brown On 07/30/2024 at 03:32 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: HEART TO HEART FAMILY CARE CENTER LLC
FACILITY NUMBER: 107208905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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/posed a potential health, safety or personal rights risk to persons in care. Licensee did not comply with the requirement above. The Carbon Monoxide detector was not present in the facility during the visit.
POC Due Date: 07/31/2024
Plan of Correction
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AD agrees to replace the detector. A picture of the new detector will be submitted to LPA via email by POC date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

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 in which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed a leaking toilet in the resident bathroom.
POC Due Date: 07/31/2024
Plan of Correction
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AD has agreed to submit a written statement which states that a plumber or maintenance professional has been contacted and scheduled to visit the facility to fix the leak. The statement will be submitted via email to LPA via email by POC date.
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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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