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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206940
Report Date: 05/29/2024
Date Signed: 08/28/2024 04:47:55 PM

Document Has Been Signed on 08/28/2024 04:47 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:ST. JOSEPH'S HOME, LLCFACILITY NUMBER:
157206940
ADMINISTRATOR/
DIRECTOR:		DANO, HAROLD AFACILITY TYPE:
740
ADDRESS:2508 OLMO CTTELEPHONE:
(661) 398-7133
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 4DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Harold DanoTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator Harold Dano.

During this visit, LPA toured the facility inside & out Resident rooms are found to be in good repair and contained required furnishings and lighting. The resident bathroom was clean and in good repair with faucets delivering hot water at 109 degrees, grab bars and non-skid mats were in place. LPA observed required hygiene items, towels, extra bedding, and linens were stored and available for use. The kitchen was clean, with necessary items and appliances knives and sharps are locked and stored separate from food. Medications are locked and centrally stored in the kitchen cabinet. The First aid kits contained required items. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. There are 2 storage sheds on property. LPA observed old beds and furnishings. AD intends to remove these from the yard. The Fire extinguishers were purchased on 4/23/24. Smoke and Carbon Monoxide detectors were tested and found to be in working condition. LPA conducted staff and resident file reviews including medication audit. Emergency Disaster Plan and Infection Control Plans were reviewed during this visit.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Incidental Medical and Dental Care Services, Care of Persons with Dementia



An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 6/11//2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Surety Bond (Lic402), Emergency Disaster Plan (LIC610E (2019), Client Roster (LIC 9020), Proof of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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 3
Document Has Been Signed on 08/28/2024 04:47 PM - It Cannot Be Edited


Created By: Katie Brown On 05/29/2024 at 01:36 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: ST. JOSEPH'S HOME, LLC
FACILITY NUMBER: 157206940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of the MAR, 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. PRN medications are being documented on the routine MAR, identified as PRN.
POC Due Date: 06/11/2024
Plan of Correction
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AD agrees to implement and train staff assisting with medication and documentation with a PRN record/log which meets all requirements. A copy of the new log and proof of training will be submitted by POC date.
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed laundry detergent and softener in a black bag under the sink in a "connon bathroom" as well as cleaning, disinfecting and bug/ant spray under the kitchen sink. The kitchen sink has a lock, which was not locked.
POC Due Date: 06/11/2024
Plan of Correction
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AD removed and secured all items during the visit. AD will provide a written statement that staff have been trained on the procedures for securing all items which could be a danger to residents. Proof of training will be submitted by POC date via fax.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/28/2024 04:47 PM - It Cannot Be Edited


Created By: Katie Brown On 05/29/2024 at 01:47 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: ST. JOSEPH'S HOME, LLC
FACILITY NUMBER: 157206940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA medication audit and record review of the Medication Administration Record (MAR), the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Facility wrote "ran out" on R1's medication card for Potassium. Med card documents that the medication ran out on 5/23/24. R1 has not received this medication 5/24, 5/25, 5/26/24. CCL, RP and PCP have not been informed.
POC Due Date: 05/30/2024
Plan of Correction
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AD agreed to purchase the Potassium which is an over the counter medication so that R1 can take the medication today and until the new card is delivered. AD agreed to conduct a staff training on the facility medication refill and documentation procedures. AD will report the medication error as ordered. AD will submit via fax a written statement that the above has been completed by 6/11/24
Type A
Section Cited
HSC
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed Milk of Magnesia and prefilled syringes stored in the kitchen refrigerator in a plastic bag
POC Due Date: 05/30/2024
Plan of Correction
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Administrator (AD) removed the medications and stored them properly during the visit. AD has agreed to purchase a small refrigerator that can store medications. This refrigerator must be able to lock or be inaccessible to residents. A picture of the new medication refrigerator with lock will be submitted via fax to CCLD by 6/11/24.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
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