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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203358
Report Date: 12/16/2024
Date Signed: 12/17/2024 08:36:54 AM

Document Has Been Signed on 12/17/2024 08:36 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:POSITIVE DIRECTIONS #9FACILITY NUMBER:
157203358
ADMINISTRATOR/
DIRECTOR:		MARIA ORTIZFACILITY TYPE:
740
ADDRESS:329 EL CAMINO DRIVETELEPHONE:
(661) 721-3525
CITY:DELANOSTATE: CAZIP CODE:
93215
CAPACITY: 4CENSUS: 3DATE:
12/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Administrator, Maria "Alicia" Ortiz TIME VISIT/
INSPECTION COMPLETED:
04:38 PM
NARRATIVE
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On 12/16/24, Licensing Program Analysts (LPAs) L. Salazar and K.Kaur arrived to the facility unannounced to conduct a case management visit based on a self reported incident received 10/14/24. LPAs were greeted by staff Diana Cervantes, stated the purpose of the visit and were allowed entry into the facility. Administrator Maria "Alicia" Oritz arrived to the facility shortly after.

On 10/14/24, LPA Salazar received a death report for Resident R1. LPA Salazar reviewed R1's file and observed the following missing documentation at the time of R1's admission on 10/08/24:

1.) Pre-Admission appraisal; 2.) Medical Assessment ; 3.) Functional capabilities; reassessment and Identification and Emergency information. Emergency information observed did not include the Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency.

On 10/08/24, Resident R1 was placed by Kern Regional Center as an emergency placement. On 10/09/24, R1 was admitted to the hospital on with a diagnosis of hypothermia and lactic acidosis. R1 was discharged from the hospital on 10/11/24 and died in the car on the way home from Delano Regional Hospital. No reassessment was completed or observed from the 10/11/24 hospital discharge.

LPA requested staff records on 10/15/24. Administrator stated staff files were at the office and would be sent via email to LPA. LPA received records on 10/30/24, 15 days after the request.

Based on observation and records review and Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809-D. If not corrected, these pose both an immediate and potential risk to the health, safety and/or personal rights of the residents in care.

Plans or corrections were developed by Administrator and reviewed with LPA, with a due date of 12/17/24. An exit interview was conducted. A copy of this report and appeal rights were provided at the time of visit. Technical Support Program was offered and accepted.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 12/17/2024 08:36 AM - It Cannot Be Edited


Created By: Lisa Salazar On 12/16/2024 at 01:08 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: POSITIVE DIRECTIONS #9
FACILITY NUMBER: 157203358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2024
Section Cited
CCR
87457(a)(1)

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87457 Pre-Admission Appraisal - General
(a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. (1) Sufficient information about the facility and its services shall be provided to enable all persons involved in the placement to make an informed decision regarding admission.
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Administrator will provide signed documentation evidencing they understand the regulation by POC.
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This requirement was not met as evidenced by LPAs observation of Resident R1's file. No preadmission appraisal was observed in file or conducted prior to R1's admission. This poses an immediate risk to the health, safety and or personal rights of the residents in care.
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Type A
12/16/2024
Section Cited
CCR87458(a)

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87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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Administrator will provide signed documentation evidencing they understand the regulation by POC.
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This requirement was not met as evidenced by LPAs observation of Resident R1s file. No medical assessment was obtained prior to admission not observed in file. This poses an immediate risk to the health, safety and or personal rights of the residents in care.
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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:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


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Document Has Been Signed on 12/17/2024 08:36 AM - It Cannot Be Edited


Created By: Lisa Salazar On 12/16/2024 at 01:40 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: POSITIVE DIRECTIONS #9
FACILITY NUMBER: 157203358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
87412(g)(1)

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87412 Personnel Records
(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f).
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Administrator will provide signed documentation evidencing they understand the regulation by POC.
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This requirement was not met as evidenced by LPAs request for staff records on 10/15/24. Administrator stated staff files were at the office and would be sent via email to LPA. LPA received records on 10/30/24, 15 days after the request. This poses a potential risk to the health, safety and/or personal rights of the residents in care.
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Type B
12/20/2024
Section Cited
CCR87405(b)(8)

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87405 Resident Record
(b) Each resident’s record shall contain at least the following information: (8) Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency.
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Administrator will provide signed documentation evidencing they understand the regulation by POC.
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This requirement was not met as evidenced by LPAs observation of R1 files. Records obtained at the time of admission did not include the required information.
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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:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


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Document Has Been Signed on 12/17/2024 08:36 AM - It Cannot Be Edited


Created By: Lisa Salazar On 12/16/2024 at 01:43 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: POSITIVE DIRECTIONS #9
FACILITY NUMBER: 157203358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2024
Section Cited
CCR
87455(c)(2)

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87455 Acceptance and Retention Limitations
(c) No resident shall be accepted or retained if any of the following apply: (2) The resident requires 24-hour, skilled nursing or intermediate care as specified in Health and Safety Code Sections 1569.72(a) and (a)(1).
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Administrator will provide signed documentation evidencing they understand the regulation by POC.
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This require was not met as evidenced by LPAs observation of R1's records facility obtained at the time of initial admission on 10/08/24 and readmission from hospital on 10/11/24. Based on interviews, R1 had conditions that facility was not aware of and the hospitalization records and death certificate are evidence of the medical conditions that were not disclosed or observed at the time of admission.
R1 was not assessed at the time of admission on 10/08/24 and also readmission on 10/11/24. This poses an immediate risk to the health, safety and or personal rights of the residents in care.
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Type A
12/27/2024
Section Cited
CCR87463(a)(3)

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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
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Administrator will provide signed documentation evidencing they understand the regulation by POC.
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This requirement was not met as evidenced by LPAs observation of R1 and R2's file. 2 out of 2 residents in care did not have reassessments completed after hospitalization's and prior to readmission back into the facility after hospital visit. This poses an immediate risk to the health, safety and or personal rights of the residents in care.
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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:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/17/2024 08:37 AM - It Cannot Be Edited


Created By: Lisa Salazar On 12/16/2024 at 02:24 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: POSITIVE DIRECTIONS #9
FACILITY NUMBER: 157203358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2024
Section Cited
CCR
87459(a)(7)(F)

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87459 Functional Capabilities
(a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to:(7) Physical condition, including:(F) Medical history and problems.
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Administrator will provide signed documentation evidencing they understand the regulation by POC.
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This requirement was not met as evidenced by LPAs review of R1 file. There is no functional capabilities assessment completed addressing medical history and problems.
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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:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


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