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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100405566
Report Date: 01/19/2023
Date Signed: 01/19/2023 02:49:21 PM


Document Has Been Signed on 01/19/2023 02:49 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:PRINCE & PRINCESS HOME FOR THE ELDERLYFACILITY NUMBER:
100405566
ADMINISTRATOR:PRINCE, BETTYFACILITY TYPE:
740
ADDRESS:4686 E. CORTLANDTELEPHONE:
(559) 231-5728
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:6CENSUS: 3DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Licensee Betty PrinceTIME COMPLETED:
02:30 PM
NARRATIVE
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On 01/19/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Licensee Betty Prince.

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas.

All pathways, entrances and exits were clear from obstructions. Facility staff observed with facial coverings.
LPA toured 2 bedrooms with adequate furnishings. At 11:26 LPA observed the facility to have debris on the floor throughout the facility. LPA toured the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in hallway was last serviced on 08/1/2022 and was fully charged. LPA observed pool to be behind a locked gate. LPA observed at 12:10 PM Facility grounds in need of cleaning. At 12:22 LPA observed the dinning room window screen to be bent/broken. LPA checked residents' medication and observed a 30-day supply. Staff files were reviewed for good health and COVID Training. LPA observed updated emergency contact information for Resident’s.

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

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/26/2023: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC
309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel
Report (LIC500), Register of Facility Clients/Residents for LIC9020. An exit interview was conducted with
Administrator. Report signed on-site; a copy of this report, 809D with appeal rights was provided. .
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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 01/19/2023 02:49 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: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)

87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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, when LPA observed the facility to have debris on the floor throughout the facility and Facility outside grounds in need of cleaning which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2023
Plan of Correction
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Licensee agrees to clean facility by POC due date.
Type B
Section Cited
CCR
80088(b)


80088(b) Furniture, Fixtures, Equipment, and Supplies

(b)All window screens shall be in good repair.

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 the dinning room window screen to be broken/bent which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2023
Plan of Correction
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Licensee agrees to repair/replace by POC due date.
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: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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