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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201038
Report Date: 11/18/2022
Date Signed: 11/18/2022 10:48:27 AM


Document Has Been Signed on 11/18/2022 10:48 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:NAN'S TLC HOMEFACILITY NUMBER:
107201038
ADMINISTRATOR:NEWELL-PARANGALAN, LUZFACILITY TYPE:
740
ADDRESS:6643 N. MAROA AVENUETELEPHONE:
(559) 439-2465
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY:6CENSUS: 4DATE:
11/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Larry and Luz Newell, LicenseeTIME COMPLETED:
11:10 AM
NARRATIVE
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On 11/18/22 at 8:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection. LPA explained reason for inspection and was granted entry into the facility. Licensees Larry and Luz Newell arrived a short time later.

LPA returned to verify correction for deficiency CCR 87303(a) issued on 10/7/22 with a Plan of Correction (POC) due date of 10/28/22. LPA observed new lock installed for door to garage requiring use of a key from the interior of the facility (kitchen) to be able to access the garage. LPA observed all excess furniture, medical equipment, and miscellaneous items from area outside on north side of facility had been removed. POC cleared.

During this inspection, LPA observed the following deficiencies:
1. S1 does not have a completed transfer of criminal record clearance. S1 was present and working. S1 has been working in the facility since 11/3/22 and has worked three days.
2. S2 did not have fingerprint criminal clearance and was present and working. S2 advises this is S2's first day of work and had not yet started the fingerprint clearance process.

Deficiencies are being cited based on LPA observations, interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. Civil penalties are being assessed in the amount of $100 per day for S1, for 3 days, and in the amount of $100 per day for S2, for 1 day, for a total of $400. See LIC421BG for more details. A civil penalty is being assessed for a repeat violation within 12 months for CCR 87355(e)(2) in the amount of $1000. See LIC421IM for more details.

Exit interview conducted and Plan of Corrections were reviewed and developed with Licensee Luz Newell. A copy of this report and appeal rights were given to Licensee Luz Newell, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
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 11/18/2022 10:48 AM - 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: NAN'S TLC HOME
FACILITY NUMBER: 107201038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
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S1 does not have a completed transfer of criminal record clearance. S1 was present and working. S1 has been working in the facility since 11/3/22 and has worked three days which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
11/19/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
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S2 did not have fingerprint criminal clearance and was present and working. S2 advises this is S2's first day of work and had not yet started the fingerprint clearance process. This poses an immediate health, 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: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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