100400448-7-19-2023-24-AS-MTHO-CTVVF3-20230719162315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 100400448
Report Date: 07/19/2023
Date Signed: 07/19/2023 04:23:19 PM

Document Has Been Signed on 07/19/2023 04:23 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 HOUSE		FACILITY NUMBER:	100400448
ADMINISTRATOR:	O'NEILL, ROSEMARY, R.N.		FACILITY TYPE:	740
ADDRESS:	2121 NORTH FIRST STREET		TELEPHONE:	(559) 237-2257
CITY:	FRESNO	STATE: CA	ZIP CODE:	93703
CAPACITY:	110	CENSUS: 69	DATE:	07/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Rosemary O'Neill, Administrator		TIME COMPLETED:	04:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 7/19/23 at 2:05 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and met with Administrator (ADM) Rosemary O'Neill.

Facility was toured with ADM. Pull station fire alarm system installed. Sample of bedrooms were checked. Centrally stored medication observed in med carts in Nurse's station. Food supply was observed in adequate supply. PPE observed stored in locked storage room.

The following deficiencies were observed:
1. Hot water in hall bathroom measured at 126.4 degrees F.

Deficiency is being cited based on LPA's observation conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

Due to time constraints, LPA will return on a later date to complete the Inspection Tool. An exit interview was conducted and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were given to Administrator, whose signature on this form confirms receipt of these documents.

The following updated forms are to be submitted to CCL within 2 weeks:

LIC610E, LIC500, LIC9020, Proof of liability insurance, LIC308

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

Document Has Been Signed on 07/19/2023 04:23 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: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Hot water in resident room PH-401 measured at 126.4 degrees F, which poses an immediate safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	Administrator will submit proof of hot water in resident room PH-401 measuring within 105-120 degrees F, to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hoffmann	TELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2