Background checksType A
- Official classification
- Type A
- Official code
- 87355(e)(2)
- Regulation authority
- CCR
What the official deficiency says
87355(e)(2) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)… This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, interview conducted and observation, S2 is working providing care and supervision for residents. S2 is fingerprinted cleared who is not associated to the facility, which poses an immediate risk to the health and safety of the residents.
Official plan of correction
POC Due Date: 01/08/2026 Plan of Correction S2 is to be removed from the facility immediately. S2 is not permitted back until associated. Licensee is to submit LIC 9182 or associate S2 on Guardian. Proof of S2 associated to the facility will be submitted to Fresno CCL by POC due date 01/08/26.
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when LPA and S2 observed cleaning solutions unlock under kitchen sink and bathroom sinks, a knife unlocked in the kitchen drawer, and chemicals unlock in the laundry room accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/08/2026 Plan of Correction Staff immediately removed and locked the chemicals and the knife. POC cleared during visit.
Health conditions and treatmentsType B
- 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: Deficient Practice Statement Based on observation and records reviewed, R1 is on hospice care and was observed lying bed using a hospital bed 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
POC Due Date: 01/16/2026 Plan of Correction Licensee shall obtain doctor orders for R1 who’s currently receiving hospice care that specific the need for full bed rails. If R1 is not eligible for hospice evaluation to retain a full bed rail, seek physician order for half bed rails and remove full bed rails. Order shall be obtained and submitted to Fresno CCL by POC due date 01/16/26.
Health conditions and treatmentsType B
- 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: Deficient Practice Statement Based on observation and records reviewed, R3 uses a ½ rail bed. There is no doctor’s order for ½ rail bed for R3, which poses/posed a potential health and safety and personal rights risk to the resident in care.
Official plan of correction
POC Due Date: 01/16/2026 Plan of Correction Licensee will obtain doctor orders for R3 indicating the need for half bed rail if physician indicates the need for half bed rail. If physician do not indicate the need for the half rails, the half rails will be removed by POC due date 01/16/26.
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(d)(3)
- Regulation authority
- CCR
What the official deficiency says
87465 (d)(3) The date and time the PRN medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews and records reviewed, R4’s PRN medication Aspirin 81mg, PRN medication Lorazepam 0.5 mg and PRN medication Ondansetron 4mg were not record in the resident’s MAR, which poses a potential health and safety risk for the person in care.
Official plan of correction
POC Due Date: 01/09/2026 Plan of Correction Licensee shall ensure that all R3’s medications are record into the resident’s MARs and will submit to Fresno CCL by the POC due date 01/09/26.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(6)
- Regulation authority
- CCR
What the official deficiency says
87465 (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview conducted, observation, and records reviewed, all 3 residents taking medications, the residents’ current medications were received and was not record in Centrally Stored Medication Record (Lic 622), poses/posed a potential health and safety and personal rights risk to the resident in care.
Official plan of correction
POC Due Date: 01/13/2026 Plan of Correction Licensee shall ensure that all the residents’ medications are recorded in the Lic 622 and submitted to Fresno CCL by POC due date 01/13/26.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)
- Regulation authority
- CCR
What the official deficiency says
87412(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview conducted, observation, and records reviewed, S2 was hired on 12/21/25 with no staff records on file, poses/posed a potential health and safety and personal rights risk to the resident in care.
Official plan of correction
POC Due Date: 01/23/2026 Plan of Correction Licensee shall ensure that facility has S2 completed file on file by POC due date. S2’s Lic 501, Lic 503 with TB results, current first aid certification, and 40 hours orientation training will submit to Fresno CCL by POC due date 01/23/26.
Health conditions and treatmentsType B
- 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 and interview conducted with Licensee, R1 and R4 are currently receiving hospice care with no 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: 01/16/2026 Plan of Correction Licensee shall obtain hospice care plan for R1 and R4 and submit it to Fresno CCL by POC due date 01/16/26.