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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209086
Report Date: 02/07/2023
Date Signed: 02/07/2023 11:36:33 AM

Document Has Been Signed on 02/07/2023 11:36 AM - 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:BK HOUSE OF GRACE LLCFACILITY NUMBER:
107209086
ADMINISTRATOR:RIEMER, ROSEMARIE HFACILITY TYPE:
740
ADDRESS:1463 N ARCHIE AVENUETELEPHONE:
(559) 201-8329
CITY:FRESNOSTATE: CAZIP CODE:
93703
CAPACITY: 6CENSUS: 5DATE:
02/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:44 AM
MET WITH:Administrator, Rosemarie Reimer and Licensee, Balwinder KaurTIME COMPLETED:
11:50 AM
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On 02/07/2023, Licensing Program Analyst (LPA) arrived unannounced to conduct a POC inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Rosemarie Reimer. Adlministrator and Licensee, Balwinder Kaur who arrived a short time later.

The purpose of this visit is to clear deficiencies issued on 01/17/2023 during an annual inspection visit. LPA conducted a facility tour and observed cleaning supplies to be locked and inaccessible to residents in care. The fire extinguisher was last serviced on 01/18/2023. LPA observed that the ceiling fan light fixture and smoke detector in bedroom 2 have been repaired.

Upon entry to the facility, LPA observed a chain and padlock around the refrigerator. Per Licensee, the facility is in the process of gathering documentation to submit to the Fresno CCL office. LPA informed Licensee, that the facility food supply cannot be locked and inaccessible to clients in care prior to obtaining an approved waiver. A citation was issued on 01/17/2023 with a plan of correction due date of 01/18/2023. As of 02/07/2023, the plan of correction has not been received. LPA will reissue the citation for the locked food supply.
A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed with Licensee. A copy of this report and appeal rights were discussed and provided to Licensee, Balwinder Kaur, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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 02/07/2023 11:36 AM - It Cannot Be Edited


Created By: Alexandria Walton On 02/07/2023 at 11:19 AM
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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited
CCR
87468.1(a)(2)

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Licensee agrees to remove the chain and padlock on the refrigerator and submit a written statement detailing the steps the facility will take to ensure the requirements for this section are met by the POC due date.
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Based on observation, the faciltiy did not ensure the above requirement was met when the facility food supply was locked and inaccessible to residents in care, which poses an immediate health and safety risk to persons in care.
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Licensee will submit a waiver request to the Fresno CCL office by 02/17/2023.

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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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023


LIC809 (FAS) - (06/04)
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