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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209141
Report Date: 11/29/2023
Date Signed: 11/29/2023 11:28:28 AM

Document Has Been Signed on 11/29/2023 11:28 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:PALO ALTO SENIOR CARE HOMEFACILITY NUMBER:
107209141
ADMINISTRATOR:TORRE VIZCARRA, MARISELAFACILITY TYPE:
740
ADDRESS:269 W. PALO ALTO AVETELEPHONE:
(310) 866-8628
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 5DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator, Marisela VizcarraTIME COMPLETED:
11:28 AM
NARRATIVE
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On 11/29/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was granted entry to the facility, facility staff contacted Administrator via telephone, and Administrator arrived a short time later. LPA met with Administrator, Marisela Vizcarra.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident bedrooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were equipped grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 128.7 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 10/16/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 07/20/2023. All cleaning supplies are locked in secured closet in the hallway. LPA reviewed staff and client records. Medications reviewed and observed to have original labels and be administered as prescribed.

A deficiency is being issued 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 the Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Marisela Vizcarra, whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/13/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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 11/29/2023 11:28 AM - It Cannot Be Edited


Created By: Alexandria Walton On 11/29/2023 at 11:07 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: PALO ALTO SENIOR CARE HOME
FACILITY NUMBER: 107209141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 the hot water in bathroom 1 measured at 128.7 degrees F, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87303 are met to the Fresno CCLD office by the POC due date The statement will include the facility's plan to measure the water temperature and document the temperature for 1 week. Water log will be submitted to the Fresno CCL office by 12/6/2023.
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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
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