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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206912
Report Date: 04/18/2022
Date Signed: 04/19/2022 09:53:15 AM

Document Has Been Signed on 04/19/2022 09:53 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:ARCADIA GARDENS RESIDENTIAL CARE IIIFACILITY NUMBER:
157206912
ADMINISTRATOR:ROURA, RODELIO L.FACILITY TYPE:
740
ADDRESS:10719 BEAVER CREEK DRIVETELEPHONE:
(661) 699-3786
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 5DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Licensee Olivia Oblea TIME COMPLETED:
01:30 PM
NARRATIVE
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On 04/18/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Lancia Griffin, Caregiver. LPA met with Licensee Olivia Oblea conduct tour with LPA. Licensee stated to LPA caregiver is not fingerprinted cleared. LPA observed caregiver providing care for residents. All five residents were present during the inspection.

Upon entry facility staffs were observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing posting. Cough etiquette posting was not observed.

LPA observed small amount of PPE supplies in facility. 30 days PPE supplies storage in a central location. Food supply was checked and appeared to be an adequate supply. At 10:30 a.m. LPA and licensee observed cleaning chemicals unlocked under kitchen sink. LPA and licensee observed cleaning supplies unlocked under kitchen sink. At 10:40 a.m. LPA and licensee observed knives in unlocked drawer. LPA and Licensee observed fire extinguisher served date: 04/04/21. At 10:50 a.m. LPA checked residents’ medications. LPA and Licensee observed medications unlock in hall cabinets.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 5 bedrooms that are single occupant. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting were not observed by bathroom sinks.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information. Continue on Lic 809C.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 04/19/2022 09:53 AM - It Cannot Be Edited


Created By: Mai Yang On 04/18/2022 at 12:26 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: ARCADIA GARDENS RESIDENTIAL CARE III
FACILITY NUMBER: 157206912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed uncleared staff person in facility providing care to the residents. Licensee stated staff person in facility providing care to the residents is not fingerprinted cleared which poses an immediate risk to the health and safety of the residents.
POC Due Date: 04/19/2022
Plan of Correction
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Staff person is to be removed from the facility immediately and not permitted back until fingerprinted cleared and associated.
Type A
Section Cited
CCR
87705(f)
87705 Care of Persons with Dementia The following shall be stored inaccessible to residents with dementia…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, two ambulatory residents present in living room when LPA and Licensee observed at 10:30 a.m. cleaning chemicals unlocked and accessible under kitchen sink. LPA and Licensee observed at 10:40 a.m. knives in kitchen cabinet unlock and accessible to residents. At 10:50 a.m., LPA and Licensee observed residents’ medications cabinets unlocked in which all poses an immediate health and safety risk to the residents.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee immediately secured the chemicals and knives in locked cabinet the laundry room. Licensee locked medications. POC cleared during visit.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/19/2022 09:53 AM - It Cannot Be Edited


Created By: Mai Yang On 04/18/2022 at 12:33 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: ARCADIA GARDENS RESIDENTIAL CARE III
FACILITY NUMBER: 157206912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)
87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Fire Extinguisher has a service date of 04/07/2021, which poses an immediate health and safety risk to the residents.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 04/19/22.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ARCADIA GARDENS RESIDENTIAL CARE III
FACILITY NUMBER: 157206912
VISIT DATE: 04/18/2022
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A deficiency and an immediate Civil Penalty of $100 was assessed. See Lic 421BG is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 04/25/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 500, Lic 610E, Lic 808, Lic 9020, control of property, and current liability insurance. LPA received copy of Administrator Certificate during facility inspection.

Licensee was informed that as COVID-19 precautionary measure, this report and appeal rights will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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