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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209251
Report Date: 12/21/2023
Date Signed: 12/21/2023 05:03:39 PM

Document Has Been Signed on 12/21/2023 05:03 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:HERITAGE CARE HOMEFACILITY NUMBER:
107209251
ADMINISTRATOR:KUMAR, ARUNFACILITY TYPE:
740
ADDRESS:167 W GOSHEN AVETELEPHONE:
5594738988
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 5DATE:
12/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Consulting House Manager (CHM) Phoeun MarezTIME COMPLETED:
05:30 PM
NARRATIVE
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During a Complaint visit on the date & times indicated above, Licensing Program Analyst (LPA) K. Mcclurg observed & reviewed the following violations with Consulting House Manager (CHM) Phoeun Marez.

Magnetic key to open drawer in kitchen containing medications observed to be accessible on metal light switch opposite drawer. Key accessibility makes medication in locked drawer accessible posing an immediate risk to residents. Key was made inaccessible at time of visit.

Staff currently working 24 hour days. Vacant resident room #1 currently being used a staff room. Rooms may not be used for any other purposes other than as designated as licensed. Room is designated as a resident room, not for use as a staff room.
Alternatives are to:
Have awake staff @ all times, including overnight,
OR
Request to change facility's license to designate a dedicated staff bedroom.
To add a designated staff room:
Licensee would need to request change of capacity to decrease capacity from 6 to 5.
If want to retain license for 6 residents, room #1 will require fire clearance for 2 residents. Initially inspected only for 1 per licensee request @ time of application.

Please submit a Letter of Intent of how issue will be addressed by due date of Plan of Correction (POC).
If adding a staff room for the time being, please indicate if would like to decrease capacity to 5 or would like to have fire clearance for 2 non-ambulatory/bedridden residents in room #1.

Please follow through with the Department to initiate desired changes by due date of (POC).
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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 12/21/2023 05:03 PM - It Cannot Be Edited


Created By: Kelly J. McClurg On 12/21/2023 at 04:16 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: HERITAGE CARE HOME
FACILITY NUMBER: 107209251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care.
Centrally stored medicines shall be kept in a safe...locked place not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Key was made inaccessible @ time of visit.Facility will develope written plan how key will be made & maintained inaccessible to resients. Plan to include commitment to do training & date(s) of training.
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Key to open locked drawer in facility kept on wall opposite locked drawer making contents accessible to residents.
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Copy of plan to be emailed to this LPA by due date.

Failure to submit POC's by due date may result in Civil Penalties.
Type B
01/05/2024
Section Cited
CCR87208(a)

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Plan of Operation.
Each facility shall have and maintain a current, written definitive plan of operation....including...plan that describes the capacities... (&)the uses intended and a designation of the rooms to be used.
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Licensee to determine if will have awake staff at all times or to designate a room for staff. Licensee to notify the Department by due date. Licensee to follow-up with Department on how to implement
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Vacant designated resident room being used as a staff bedroom.
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changes if needed.
Licensee may email notification of decision to the LPA. Please reference facility by name & number. Include follow-up contact telephone number.
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:See Moua
LICENSING EVALUATOR NAME:Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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