WESTCARE CALIFORNIA, INC.

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Contact Information
Licensee Name
WESTCARE CALIFORNIA, INC.
2772 S. Martin Luther King Boulevard, Fresno, CA 93706
Facility Name
Identification Number
100010FN
Reviews & Findings
Dates of Review
September 6-7, 2016
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Title 9, Section 10564(c) Personnel Requirements Class B

The above section states, in part,
(c) “In addition to the requirements of (b) of this regulation, program staff who provide counseling services (as defined in Section 13005) shall be licensed, certified, or registered to obtain certification pursuant to Chapter 8 (commencing with Section 13000).”

The licensee was deficient in meeting this regulation because the employee files did not contain current counseling registration (expired on April 22, 2015), for employee number #5.

2) Title 9, Section 10564(e)(1) Personnel Requirements Class B

The above section states, in part,
(e) All personnel shall be in good health.
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed under licensed medical supervision not more than sixty (60) days prior to or seven (7) days after employment with tuberculosis testing renewable every year.”

The licensee was deficient in meeting this regulation because the employee file did not contain current tuberculosis test results (due no later than for employee number.

3) Title 9, Section 10564(1)(1) Personnel Requirements Class C

The above section states, in part
(I) The licensee shall maintain personnel records for all staff, including program administrators, containing:
(1) Name, address, telephone number, position, duties, and date of employment

The licensee was deficient in meeting this regulation because the employee file did not contain the employee’s job description and/or duties, for employee number #4.

4) Title 9, Section 10564(1)(2) Personnel Requirements Class C

The above section states, in part
(I) The licensee shall maintain personnel records for all staff, including program administrators, containing:
(2) Resumes,applications, and/or transcripts documenting work e to meet the requirements of this regulation.

The licensee was deficient in meeting this regulation because the employee file did not contain the application for employee number #4.

Deficiencies 2

5) Title 9, Section 10565(a)(2) Personnel Records Class C

The above section states, in part
(a) Personnel records shall be completed and maintained for each employee, shall be available to the department for review, and contain the following information:
(2) Driver’s license number, class, and expiration date if the employee is to transport residents.

The licensee was deficient in meeting this regulation because the employee file did not contain a current driver’s license (though not determined if these employees’ ever transport resident’s), for employee numbers #14, #16, #18 and #19.

6) Title 9, Section 10566(b)(2)(A) Admission Agreements Class C

The above section states, in part
(b) Admission agreements shall specify the following:
(2) Payment provisions.
(A) Amount assessed.

The licensee was deficient in meeting this regulation because the admission agreement did not specify the amount that the resident had to pay for his or her treatment, residents.

7) Title 9, Section 10566(c) Admission Agreements Class C

The above section states, in part
(c) Such agreements shall be dated and signed by the resident and the licensee no later than seven (7) days following admission.

The licensee was deficient in meeting this regulation because the admission agreement was not signed nor dated by the staff member, resident.

8) Title 9, Section 10584(b) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, in part,
(b) “All window screens shall be in good repair and free of insects, dirt and other debris.”

The licensee was deficient in meeting this regulation because the window screen in bedroom #61 was torn, allowing for the possibility of insect and flies to enter the room.

Note: This deficiency was cleared prior to exit.

9) Title 9, Section 10584(c) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, in part,
(c) “The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the safety of all persons in the facility.”

The licensee was deficient in meeting this regulation because light fixtures in several areas throughout the facility had burnt out bulbs.

Note: This deficiency was cleared prior to exit.

10) Section 17015(d)(2) Participant Files

The above section states, in part,
(d) Other requirements
(2) All entries shall be signed end dated.

The provider was deficient in meeting the above standard because the admission agreement was not signed nor dated by the intake staff member, participant number.

Deficiencies 3

3) Section 17020(a)(5) Continuous Quality Management

The above section states, in part,
(a) Continuity of Activities
(5) The recovery or treatment plan is reviewed by the participant and updated as necessary at least every 90 days.”

The provider was deficient in meeting the above standard because: Refer to Deficiency#1.

4) Section 19005(b)(1-7) Personnel Policies

The above section states, in part,

(b) “The program shall maintain personnel files for all employees. Each personnel file shall contain:

1. Application for employment and resume;
2. Employment confirmation statement;
3. Job description;
4. Salary schedule and salary adjustment information;
5. Employee evaluations;
6. Health records including a health screening report or health questionnaire, and tuberculosis test results as required; and
7. Other personnel actions (e.g., commendations, discipline, status change, employment incidents, and/or injuries).”

The provider was deficient in meeting the above standard because the following items were missing from the employees’ file:

(1) No job application for employee #4.
(2) No job description for employee #4.
(3) No current employee performance evaluation for employee#’s 8, 9, 13, 14, 15, 16, 17 and 18.
(4) No current tuberculosis test results for employee

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 215
Census: 177

TREATMENT CAPACITY:
Approved: 265
Census: 203