DEVOTED HEARTS SENIOR CARE HOME LLC #2

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the licensee did not comply with the section cited above when LPA and L1 observed sliding exit door in room 4 blocked with a metal leaver rod preventing sliding exit door to open, which an immediate health and safety risk which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/20/2026 Plan of Correction Licensee immediately removed the metal stick. POC cleared during visit.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident… This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above when LPA reviewed R1 and R2 whose currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/20/2026 Plan of Correction Licensee obtained R1 and R2’s hospice care plan from Hospice agency during visit. POC cleared during visit.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

87303(e)(5) Slip resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above when no nonskid mat or strips was observed in the master bathroom shower, which poses a potential health or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/23/2026 Plan of Correction Licensee will obtain a nonskid mat in master bathroom shower by POC due date and submit proof to Fresno CCL by POC due date 02/23/26.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

HSC 1569.625(b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when all personnel training was not observed on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility shall ensure all staff are trained and training documents are on file. Licensee stated all staff training will be completed by 10/27/25. Staff trainings record shall be submitted to the Fresno CCL by POC due date 10/27/25.

Deadline recorded: Oct 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when LPA reviewed staff files and no health screening were observed on file for 3 out of 4 staff, which poses a potential health or personal rights risk to persons in care.

Official plan of correction

Licensee will submit proof of S1, S2, and S3's health screening to Fresno CCL office by POC due date 10/20/25.

Deadline recorded: Oct 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

87211(a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on record review and interviews: the licensee did not ensure a written was submitted to the Fresno CCL office within 7 days of occurrence on 09/09/25 when R5 went to the hospital, this poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit a plan detailing steps the facility will take to ensure the requirements of Reporting requirements are met by the POC due date 10/10/25.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(21)

Regulation authority

CCR

What the official deficiency says

87555 (b)(21) Freezers of adequate size ...They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by: Based on observation, the refrigerator in the garage was observed dirty food grime inside on the bottom.

Official plan of correction

Staff cleaned the garage refrigerator during visit. POC cleared during visit.

Deadline recorded: Oct 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident… This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when LPA review R1’s file, whose currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.

Official plan of correction

Licensee will obtain R1’s hospice care plan and submit it to Fresno CCL by POC due date 10/10/25.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on observation and records reviewed, R3 who do not received hospice care were observed with half with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

Licensee removed half rails during visit. POC cleared during visit.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on records review, two out of 6 residents do not have appraisals and needs and services plan on file, which poses/posed a potential health and safety and personal rights risk to the residents in care.

Official plan of correction

Licensee will complete and obtain appraisal and needs and services plan for R2 and R3 by POC due date. Copies will be submitted to Fresno CCL by POC due date 10/13/25.

Deadline recorded: Oct 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation and records reviewed, R2 who receives hospice care were observed with full rail with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

Licensee will obtain order for full rail bed for R2 and submitted to the Fresno CCL by POC due date 10/10/25.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

1569.618 (c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: All staff files were reviewed, and interviews conducted, staffs not have current First Aid and CPR certification, this poses an immediately health and safety risk for the residents in care.

Official plan of correction

Licensee shall ensure that all staff have current First Aid/ CPR certification. Proof of all staff First Aid/ CPR certification is to be submitted to the Fresno CCL by 10/07/25.

Deadline recorded: Oct 7, 2025. A deadline is not proof that correction was completed.