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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201055
Report Date: 04/19/2024
Date Signed: 04/22/2024 09:53:25 AM


Document Has Been Signed on 04/22/2024 09:53 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:GARDEN TERRACE ASSISTED LIVING IIFACILITY NUMBER:
107201055
ADMINISTRATOR:HERGENROEDER, STEVE & JULIFACILITY TYPE:
740
ADDRESS:1743 E. CHENNAULTTELEPHONE:
(559) 323-1083
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
04/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Julie HergenroederTIME COMPLETED:
11:55 AM
NARRATIVE
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On 04/19/2024, Licensing Program Analyst (LPA) Gorban conducted a case management in response to requested facility files for complaint investigation office requested on 2/23/2024

LPA Gorban met with facility Administrator Juli Hergenroeder and discussed with administrator the following. Based on department request, facility failed in timely manner to report medication refusal by resident (R1).

Citation for this report will be issued during this visit on the following, LIC809-D.

Exit interview conducted. Report signed and a copy of this report with appeal rights provided to administrator for facility records.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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 04/22/2024 09:53 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: GARDEN TERRACE ASSISTED LIVING II
FACILITY NUMBER: 107201055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/25/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified below. This was not observed as evidenced by:
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The facility administrator will review title 22, provide staff training and submit to LPA by email by POC due date
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The facility failed to provide the Licensing department with R1 refusal of medication intake on multiple occations: 2/9/24, 2/10/24, 2/11/24, 2/12/24, 2/17/24, 2/18/24, and 2/19/24 wich poses potential safety risc 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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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