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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400448
Report Date: 06/12/2024
Date Signed: 06/12/2024 01:13:53 PM

Document Has Been Signed on 06/12/2024 01:13 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:NAZARETH HOUSEFACILITY NUMBER:
100400448
ADMINISTRATOR/
DIRECTOR:		O'NEILL, ROSEMARY, R.N.FACILITY TYPE:
740
ADDRESS:2121 NORTH FIRST STREETTELEPHONE:
(559) 237-2257
CITY:FRESNOSTATE: CAZIP CODE:
93703
CAPACITY: 110CENSUS: 78DATE:
06/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Assistant Director Sara Guidry and Administrator Rosemary O’Neill TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 6/12/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct a continuation Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA met with Assistant Director Sara Guidry.

LPA observed Pull station fire alarm system installed. Sample of bedrooms were checked. Centrally stored medication observed in med carts in Nurse's station. A sample medication audit was conducted. LPA observed Paint cans in the courtyard backyard sitting next to the wall; accessible to residents in care.



Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with staff. Report signed on-site; a copy of this report, 809D with appeal rights will be provided via email due to technical difficulties.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 06/12/2024 01:13 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 06/12/2024 at 10:06 AM
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: NAZARETH HOUSE
FACILITY NUMBER: 100400448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 areas paint cans observed in cabinet and backyard courtyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Administrator to conduct in service training regarding locking all chemical items immediately after use. Paint was removed immediately and locked during inspection.
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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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