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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400448
Report Date: 04/23/2024
Date Signed: 04/23/2024 04:05:10 PM


Document Has Been Signed on 04/23/2024 04:05 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: 80DATE:
04/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Assistant Director Sara Guidry and Administrator Rosemary O’NeillTIME COMPLETED:
02:45 PM
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Licensing Program Analyst LPA K.Kaur conducted a Case Management to follow up on two incidents that were reported to CCLD that occurred on 1/18/2024 and 3/13/2024. LPA was met with Assistant Director Sara Guidry and Administrator Rosemary O’Neill. LPA discussed the purpose of the visit.

LPA interviewed staff regarding incidents. Regarding Incident dated 1/18/2024 for resident’s (R1) funds that went missing facility provided a short-term fix by reimbursing residents family the missing monies. For a long term fix the facility and family decided to not have such large amounts of cash kept with the resident. Facility notified Licensing, Ombudsman, and Police department. Facility followed proper procedures. No deficiencies cited.

Regarding Incident dated 3/13/2024 Resident (R2) medication error. Per Administrator Resident medication was not discontinued on the MARs and resident received medication in error. Based on record review LPA observed MARs dated 3/1/2024 to 3/12/2024 with two entries for the same medication with the same dosage that was being given twice a day.

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

An exit interview was conducted with Administrator discussing the plan of corrections. Report signed on-site; a copy of the report with 809D page and appeal rights will be emailed due to technical difficulties.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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 04/23/2024 04:05 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: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2024
Section Cited
CCR
87465(a)(4)

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87465(a)(4) The licensee shall assist residents with self-administered medications as needed.


This requirement is not met as evidenced by:
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Plan of Correction Administrator agrees to submit medication training on administration and logging of all medication, which will include an agenda, qualified presenter and staff signatures.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for Resident (R2) who was receiving the same medication/dose twice a day since two entries were made into the MARs one for bedtime and one entry for “daily” in error which poses an immediate health, safety or personal rights risk to persons 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: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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