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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208941
Report Date: 03/25/2024
Date Signed: 03/25/2024 02:27:45 PM

Document Has Been Signed on 03/25/2024 02:27 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:ARCADIA FAMILY CARE IVFACILITY NUMBER:
157208941
ADMINISTRATOR:YATCO, JASMINFACILITY TYPE:
740
ADDRESS:13511 HINAULT DRTELEPHONE:
(661) 615-3312
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 5DATE:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Licensee, Jerry Yatco and Administrator, Jasmin YatcoTIME COMPLETED:
02:41 PM
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On 03/25/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Licensee, Jerry Yatco and Administrator, Jasmin Yatco.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 115.9 degrees F and 118 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 01/17/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Cleaning supplies are locked in secured under kitchen sink. Last fire drill was conducted on 02/03/2024. LPA reviewed staff and client records. Upon review of records, LPA found that 4 out of 5 resident did not have a complete and current hospice care plan. Medications reviewed and appeared to be administered as prescribed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/08/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020A), Surety Bond.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report was discussed and provided to Licensee, Jerry Yatco, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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 03/25/2024 02:27 PM - It Cannot Be Edited


Created By: Alexandria Walton On 03/25/2024 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: ARCADIA FAMILY CARE IV
FACILITY NUMBER: 157208941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(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
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Based on record review, the licensee did not comply with the section cited above when 4 out of 5 residents did not have a complete and current hospice care plan, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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Licensee agrees to obtain a complete and current hospice care plans for 4 out of 5 residents in care and submit a copy of the care plan to the Fresno CCL office by the POC due date.
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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024


LIC809 (FAS) - (06/04)
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