Community Care Licensing

Document Has Been Signed on 12/18/2024 03:16 PM - It Cannot Be Edited

FACILITY NAME:	CROMWELL HAVEN		FACILITY NUMBER:	107209181
ADMINISTRATOR/ DIRECTOR:	YOLANDA CASTIGADOR		FACILITY TYPE:	740
ADDRESS:	5787 W. CROMWELL AVE.		TELEPHONE:	(925) 470-9712
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY: 6		CENSUS: 5	DATE:	12/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:58 AM
MET WITH:	Percival Tobias		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

SUPERVISORS NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024

Link to Parent Document Below:

FACILITY NAME: CROMWELL HAVEN	FACILITY NUMBER: 107209181
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2024

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Documentation is not retained that records complete Initial or Annual staff training. S1 and S2 were reviewed during the visit
	POC Due Date: 01/20/2025
	Plan of Correction
1 2 3 4	Licensee has agreed to create a procedure to record staff initial, medication and annual training requirements. A copy of S1 and S2's initial and annual training will be submitted to CCL by poc date.

Type B

Section Cited

CCR

87458(b)(5)

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. R1's current Physician's Report states R1 is Ambulatory. Per Licensee description of R1's change of condition, R1 is non-ambulatory.
	POC Due Date: 01/20/2025
	Plan of Correction
1 2 3 4	Licensee has agreed to conduct a Reappraisal of R1 as well as obtain a new Physician' Report. The report will be reviewed for completeness and accuracy. A copy of the new Physician's Report and Reappraisal will be submitted to CCL by poc date.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024

Link to Parent Document Below:

FACILITY NAME: CROMWELL HAVEN	FACILITY NUMBER: 107209181
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2024

Type B

Section Cited

CCR

87608(a)(1)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. R5 has a hospital with both half side rails. The Physician Order states the rails are for safety, not positioning.
	POC Due Date: 01/20/2025
	Plan of Correction
1 2 3 4	Licensee agrees to obtain a revised Physician Order for R5's hospital bed and half side rails. A copy of the revised order will be submitted to CCL by poc date.

Type B

Section Cited

CCR

87609(b)(4)

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. R1 is currently receiving Home Health Nursing services. The facility does not have a written agreement on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).
	POC Due Date: 01/20/2025
	Plan of Correction
1 2 3 4	Licensee agrees to create a Home Health Agency written agreement which will be used upon any resident on Home Health. The agreement will include documentation be left at the facility by the Nurse which reflects the care provided and additional required information. Licensee will meet with a Home Health representative to complete the agreement for R5. A copy of R5's Home Health Agreement will be submitted to CCl by poc date.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024

Link to Parent Document Below:

FACILITY NAME: CROMWELL HAVEN	FACILITY NUMBER: 107209181
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2024

Type B

Section Cited

CCR

87633(b)

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents receiving Hospice care which poses/posed a potential health, safety or personal rights risk to persons in care. R2 and R3 files were reviewed. The files did not contain the Hospice plans of care (poc). Licensee confirmed they did not have them.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	DEFICIENCY CLEARED DURING THE VISIT During the visit, Licensee obtained the hospice plan of care for R2 and R3.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024