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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209141
Report Date: 10/28/2024
Date Signed: 10/28/2024 11:57:39 AM

Document Has Been Signed on 10/28/2024 11:57 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/
DIRECTOR:		TORRE VIZCARRA, MARISELAFACILITY TYPE:
740
ADDRESS:269 W. PALO ALTO AVETELEPHONE:
(310) 866-8628
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 4DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Administrator, Marisela VizcarraTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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On 10/28/2024, 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 met with Administrator, Marisela Vizcarra.

LPA reviewed facility records and observed the following: LPA found that 3 out of 4 client records were observed to be current and complete. LPA did not observe hospice binder for S1. Administrator stated that hospice nurse completed a binder and requested for another agency "drop off" the binder to the facility. Personnel records reviewed. LPA found personnel records to be complete, however staff did not have documentation of annual training on file. Medications reviewed and observed to be administered as prescribed. Emergency disaster plan reviewed. Last fire drill conducted on 09/14/2024.

LPA conducted a tour of the facility. Facility appeared clean and at a comfortable temperature. Common areas were furnished with adequate seating and lighting. Fire extinguisher observed to be last serviced on 10/16/2023. LPA toured the facility kitchen. Kitchen appeared clean and safe for food preparation. LPA observed an adequate food supply. Medications observed to be locked and inaccessible in a cabinet in the kitchen. LPA observed the facility bathroom to be operational. Bathroom was equipped with securely fastened grab bars. Hot water measured at 116.4 degrees F. Cleaning supplies observed to be locked an inaccessible in a closet. LPA toured resident bedrooms and observed the bedrooms to have required furnishings. LPA observed an adequate supply of linens. Smoke detector and carbon monoxide detector observed to be operational during today's inspection.

Exterior tour conducted. All exits and passage ways were free from obstructions during today's inspection.

Deficiencies are 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 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 via fax or mail by 11/11/2024: 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: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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 10/28/2024 11:57 AM - It Cannot Be Edited


Created By: Alexandria Walton On 10/28/2024 at 11:31 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)(2)
87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations


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 fire extinguisher was last serviced on 10/16/2023, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Licensee agrees to have the fire extinguisher serviced and submit proof of service to the Fresno CCL office by the POC due 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2024 11:57 AM - It Cannot Be Edited


Created By: Alexandria Walton On 10/28/2024 at 11:38 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: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when facility staff did not have current training documentation on file safety or personal rights risk to persons in care
POC Due Date: 11/04/2024
Plan of Correction
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Licensee will submit a copy of udpated training to the Fresno CCL office by the POC due date.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when S1 did not have a current and complete hospice plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the facility's plan to obtain a complete hospice care plan for S1 to the Fresno CCL office by the POC due 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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