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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209086
Report Date: 03/06/2023
Date Signed: 03/06/2023 01:17:38 PM

Document Has Been Signed on 03/06/2023 01:17 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: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: 6DATE:
03/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Facility Staff, Mary Tibon and Administrator, Rosemarie Riemer via telephoneTIME COMPLETED:
01:32 PM
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On 03/06/2023, Licensing Program Analyst (LPA) Walton 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, Mary Tibon, contacted Administrator, Rosemarie Riemer via telephone. LPA received verbal permission to have facility staff signed the report.

The purpose of this visit is to follow up on a deficiency issued on 02/07/2023 during an POC inspection visit.

Upon entry to the facility, LPA observed a chain and padlock around the refrigerator. LPA spoke with Administrator, Rosemaire Riemer (AD) via telephone. LPA informed AD that the POC documentation submitted was incomplete and the facility needs to submit supporting documentation, as previously requested. LPA informed AD that the facility cannot lock the refrigerator until an exception is granted to the facility. LPA instructed AD to remove the chain and padlock until the facility receives approval. LPA will reissue the citation for the locked food supply since a complete POC has not been received.

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 Facility Staff, Mary Tibon, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
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 03/06/2023 01:17 PM - It Cannot Be Edited


Created By: Alexandria Walton On 03/06/2023 at 01:04 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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2023
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 submit a exception request for a waiver to lock the facility refrigerator as well as supporting documention to the Fresno CCL office 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 was informed to remove the chain and padlock from the refrigerator until the facility has received approval

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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: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023


LIC809 (FAS) - (06/04)
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