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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201156
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:22:33 PM

Document Has Been Signed on 02/04/2025 03:22 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:FAIRWINDS - WOODWARD PARKFACILITY NUMBER:
107201156
ADMINISTRATOR/
DIRECTOR:		VALERO, DESIREEFACILITY TYPE:
740
ADDRESS:9525 N FT WASHINGTON RDTELEPHONE:
(559) 434-6444
CITY:FRESNOSTATE: CAZIP CODE:
93730
CAPACITY: 270CENSUS: 269DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator Desiree ValeroTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 02/02/25, Licensing Program Analyst (LPA) K. Kaur conducted a required unannounced Annual Inspection visit. LPA introduced herself, stated purpose of visit, and met with Administrator Desiree Valero.

LPA toured the facility inside and out to include entry, dining area, common areas on all 3 floors, sample of bedrooms, bathrooms, and exterior. LPA observed License, Fire clearance, and personal rights posted in the facility. LPA did not observe Residential Care Facility for the Elderly RCFE Complaint Poster (PUB 475) posted in the main entryway of the facility. Facility has individual apartments for residents with individual bathrooms. Residents do not share bedrooms except couples. LPA observed resident rooms with chemicals, disinfectants, cleaning solutions, knives and sharp objects. All fire exit routes were clear and free from obstructions. LPA observed facility to be clean, clutter free, and odor free. Fire extinguishers were last serviced 8/12/2024 and are in good standing. Sample of staff files were reviewed. Staff files had health screenings/ TB Clearance. It was verified that current staff on duty are CPR certified.

Due to time constraints, LPA will return later for an annual continuation.

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

LPA is requesting the following documents be submitted to the Fresno CCL office by 2/11/2025: 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 LIC9020.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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 is an Amendment of Original Document on 02/20/2025 11:46 AM


Created By: Kamaldeep Kaur On 02/04/2025 at 02:50 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: FAIRWINDS - WOODWARD PARK
FACILITY NUMBER: 107201156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 6 bedrooms were observed with chemicals, disinfectants, cleaning solutions. Bedroom is shared by a couple and 602 review revealed R1 is not allowed to have access to chemicals/ medications. Bistro area had chemicals in unlocked cabinets and housekeeping cart was unlocked in the hallway with chemicals which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Administrator agrees to submit a statement of intent by due date to provide in service training to staff and conduct a facility sweep to remove all items. After completion of training and removal of items documentation will be submitted to CCLD.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/04/2025 03:22 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/04/2025 at 02:50 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: FAIRWINDS - WOODWARD PARK
FACILITY NUMBER: 107201156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) was not posted in the main entryway of the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
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Administrator agrees to provide proof of purchase or submit picture as proof by 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 Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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