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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400448
Report Date: 08/01/2023
Date Signed: 08/01/2023 05:22:50 PM


Document Has Been Signed on 08/01/2023 05:22 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:O'NEILL, ROSEMARY, R.N.FACILITY TYPE:
740
ADDRESS:2121 NORTH FIRST STREETTELEPHONE:
(559) 237-2257
CITY:FRESNOSTATE: CAZIP CODE:
93703
CAPACITY:110CENSUS: 69DATE:
08/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Assistant Administrator Sara GuidryTIME COMPLETED:
05:46 PM
NARRATIVE
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On 8/1/23 at 4:30 PM, Licensing Program Analyst (LPA) Malia Thao conducted a follow up case management - incident inspection. LPA explained reason for inspection and met with Assistant Administrator Sara Guidry.

During the inspection on 2/22/23, LPA investigated the incident that occurred on 2/1/23 involving S1 and R1. Facility self reported the incident where S1 slapped R1. S2 stated S2 witnessed S1 slap R1 on the head and/or neck area. S1 admitted the abuse to a facility supervisor. S1 was terminated the following day. Facility made the report to CCL and local law enforcement the day following the incident. No charges were made against S1 by law enforcement. R1 did not receive any injuries.

A deficiency is being cited based on LPA interviews and record review conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and a Plan of Correction was reviewed and developed with the Assistant Administrator Sara Guidry. A copy of this report and appeal rights were given to Assistant Administrator, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
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 08/01/2023 05:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: NAZARETH HOUSE
FACILITY NUMBER: 100400448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2023
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

This requirement was not met as evidenced by:
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Facility terminated S1 the following day. Administrator will submit proof of an in-service training/roster on resident personal rights, to CCL by POC due date.
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Facility self reported the incident where S1 slapped R1. LPA investigated the incident and found that S2 witnessed S1 slap R1 on the head and/or neck area, and S1 admitted the abuse to a facility supervisor. This poses a potential 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: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
LIC809 (FAS) - (06/04)
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