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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209013
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:41:58 PM

Document Has Been Signed on 10/27/2021 03:41 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:ATTENTIVE SENIOR CARE II, LLCFACILITY NUMBER:
107209013
ADMINISTRATOR:HOLLAND, LAWRENCEFACILITY TYPE:
740
ADDRESS:6149 E LOWE AVETELEPHONE:
(916) 996-6215
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 5DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Paulette Holland, LicenseeTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/27/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with caregiver Latoya Holland. Caregiver call Administrator Lawrence Holland and Licensee Paulette Holland. LPA conduct tour with caregiver. Administrator and Licensee arrived later during tour. Four residents were present during the inspection.

Facility staff was observed with mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Social distancing postings in facility. Cough etiquette postings were not observed in facility. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues.

LPA checked residents’ locked medications. A 30-day PPE supplies were not observed. LPA observed a bleach bottle under unlocked kitchen sink. Food supply was checked and appeared to be an adequate supply. LPA observed a paint can and laundry detergent unsecured and unlocked in garage cabinet.

All bathrooms are observed with trash cans with lid and securely fastened grab bars. Bathrooms have non-skid mat. No hand washing sign by bathroom sinks. LPA observed a bleach bottle in unlock hall cabinet. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 2 shared resident’s bedrooms to be at least 6 feet apart and 1 bedroom that are single occupant.

The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed fire extinguisher serviced date: 10/27/20. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit interview was conducted. A plan of correction was developed and reviewed with the administrator. The following documents are requested and submitted to Fresno CCL by: 11/2/21. The following updated forms were requested: Lic 308, Lic 309, Lic 500, and Lic 9020. LPA received copy of updated Lic 610E during facility inspection. Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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 10/27/2021 03:41 PM - It Cannot Be Edited


Created By: Mai Yang On 10/27/2021 at 01:39 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: ATTENTIVE SENIOR CARE II, LLC
FACILITY NUMBER: 107209013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(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 when LPA observed 1 bottle of bleach under the unlocked kitchen sink, 1 bottle of bleach in unlocked hall cabinet, 1 paint can in unlock garage cabinet , and 2 laundry detergent in unlocked garage cabinet accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2021
Plan of Correction
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Licensee and caregiver immediately removed the bottle of bleach from under the kitchen sink and hall cabinet and placed the bottles in a locked cabinet. Licensee and caregiver immediately removed the paint can and 2 laundry detergent from the unlocked cabinet in the garage and placed the paint cans in a locket cabinet. POC cleared during visit.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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