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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202569
Report Date: 05/05/2023
Date Signed: 05/08/2023 09:20:48 AM

Document Has Been Signed on 05/08/2023 09:20 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MADONNA GARDENSFACILITY NUMBER:
275202569
ADMINISTRATOR:PATRICIA KINGFACILITY TYPE:
740
ADDRESS:1335 BYRON DRTELEPHONE:
(831) 758-0931
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY: 88CENSUS: 48DATE:
05/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Tyler Barnes TIME COMPLETED:
03:00 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Sarah Hurt arrived to the facility unannounced to conduct a Case Management visit, and met with facility Administrator Tyler Barnes.

LPA Hurt observed during facility tour all outer doors to Resident bedrooms in Memory Care area of the facility to be locked. Administrator Tyler stated the outer doors are locked so residents can not easily access each others rooms. The facility staff has keys to Resident bedrooms on them and can access doors.

The following deficiency is being cited today Per Title 22 Regulations, Division 6, Chapter 8.

Exit interview conducted with Administrator Tyler Barnes and a copy of this report provided.


SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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 05/08/2023 09:20 AM - It Cannot Be Edited


Created By: Sarah Hurt On 05/05/2023 at 02:38 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: MADONNA GARDENS
FACILITY NUMBER: 275202569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/06/2023
Section Cited
CCR
87705(c)(1)

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills. The following requirement has not been met as evidenced by:
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Administrator Tyler Barnes will unlock all memory care resident bedroom doors and send proof to LPA by POC date of 05/06/2023.
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LPA Hurt observed all Memory Care facility doors to be locked preventing emergency personnel services from easily entering rooms which poses an immediate health, safety, or personal rights risk to 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:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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