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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100405365
Report Date: 11/13/2023
Date Signed: 11/16/2023 08:24:44 AM

Document Has Been Signed on 11/16/2023 08:24 AM - 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:DAILEY'S HOME CAREFACILITY NUMBER:
100405365
ADMINISTRATOR:MEDINA, MYSTIFACILITY TYPE:
735
ADDRESS:4690 EAST HAMILTONTELEPHONE:
(559) 456-9440
CITY:FRESNOSTATE: CAZIP CODE:
93702
CAPACITY: 6CENSUS: 6DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Estelle DaileyTIME COMPLETED:
03:00 PM
NARRATIVE
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On 11/13/2023, Licensing Program Analyst LPA(s) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff Sylvia Garcia. Staff called Licensee Estelle Dailey who arrived a short while later.

LPA conducted tour with Staff. The facility was observed to be at a comfortable temperature, clean, in good repair, with no passageway obstructions or fire hazards. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the Kitchen was last serviced on 02/03/2023 and was fully charged. All common areas were properly furnished and well-lit throughout. Medications, First Aid, Resident/Staff files, and Sharp items locked in the hallway closet. Smoke Alarm and Carbon Monoxide detector tested and operational.

LPA toured 4 resident rooms and an office. All client bedrooms toured and observed to be adequately furnished. Extra linens observed in the hallway closet. LPA toured laundry area which appeared clean. LPA observed unlocked laundry detergent and softener. Additional cleaning supplies and chemicals observed locked in the enclosed patio cabinets. The exterior tour was conducted. Backyard observed to have sufficient seating under covered enclosed patio. Medication was reviewed. Staff records were reviewed for good health and training, all clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. Last fire drill completed on 10/27/2023.

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

LPAs is requesting the following documents be submitted to the Fresno CCL office by 11/20/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. Report signed on-site, a printed copy was provided including appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/16/2023 08:24 AM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 11/13/2023 at 02:30 PM
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: DAILEY'S HOME CARE
FACILITY NUMBER: 100405365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 1 out of 1, LPA observed laundry detergent and unlocked in the laundry room and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2023
Plan of Correction
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Licensee removed chemicals and locked them in the garage. POC cleared during visit ****** Licensee will ensure chemicals
are locked going forward at all times.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/16/2023 08:24 AM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 11/13/2023 at 02:35 PM
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: DAILEY'S HOME CARE
FACILITY NUMBER: 100405365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)


This requirement is not met as evidenced by:

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1, LPA observed laundry detergent and unlocked in the laundry room and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2023
Plan of Correction
1
2
3
4
Licensee removed chemicals and locked them in the garage. POC cleared during visit ****** Licensee will ensure chemicals
are locked going forward at all times.
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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 7 of 7