107201450-1-9-2024-24-AS-KKAR-CZBU7Y-20240109142043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201450
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:20:55 PM

Document Has Been Signed on 01/09/2024 02:20 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:	CHRISTINA'S CARE HOME		FACILITY NUMBER:	107201450
ADMINISTRATOR:	STEPHEN, RAVI		FACILITY TYPE:	740
ADDRESS:	2551 MESA AVENUE		TELEPHONE:	(559) 347-9900
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 6	DATE:	01/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Care Coordinator Luijean De Castro Abragan		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/09/2024, Licensing Program Analyst (LPA) 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 John Trinos. Licensee /Administrator was unavailable. Care Coordinator Luijean De Castro Abragan arrived a short while later. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions were observed inside or outside. Common areas were properly furnished and well-lit throughout. LPA toured the facility with the staff. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available in hallway closet. Hot water temperature measured at 113.5 degrees F. LPA observed grab bars installed by toilet and non-skid mats in place. At 10:45 AM LPA observed no Carbon monoxide detector at the facility. Smoke alarm detectors installed and operational. The dining room is equipped with a table and chairs, the living room is equipped with adequate sofas and recliners for seating. At 11:13 PM LPA observed insufficient non-perishable foods. LPA observed a 2-day supply of perishable foods observed. Knives were locked in the kitchen cabinet. Cleaning supplies observed locked in the cabinet under the kitchen sink. Medications observed locked in the upper kitchen cabinets. The fire extinguisher in kitchen was serviced 1/20/2023. Adequate outside space for rest and recreational seating observed under covered patio. The backyard gate is self-closing and self-latching. At 12:10 PM LPA observed current Resident’s Cash resources form to be unavailable as well as the funds. LPA observed one resident's (R1) file to be missing a TB Test. LPA observed all other resident documents on file. LPA reviewed residents’ medication, MARS and Centrally Stored Medication list (CSMDR) and observed Continued on LIC809C...

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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 01/09/2024 02:20 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: CHRISTINA'S CARE HOME	FACILITY NUMBER: 107201450
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	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 no Carbon Monoxide Detector at the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2024
	Plan of Correction
1 2 3 4	Staff had a carbon monoxide detector brought to the facility during inspection which was observed operating. POC cleared during the inspection.

Type A

Section Cited

CCR

87555(a)

General Food Service Requirements

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1out of 1; LPA observed LPA observed insufficient non-perishable foods which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2024
	Plan of Correction
1 2 3 4	Licnesee to stock 7-day non-perishable food for 6 residents and submit pictures to CCLD 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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/09/2024 02:20 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: CHRISTINA'S CARE HOME	FACILITY NUMBER: 107201450
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87506(b)(16)

Resident Records

(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 resident's file observed withouth cash resources and funds which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2024
	Plan of Correction
1 2 3 4	Licensee to complete Cash Resources form LIC405 and submit copies to CCLD by due including documentation of residents funds.

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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/09/2024 02:20 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: CHRISTINA'S CARE HOME	FACILITY NUMBER: 107201450
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 residents medication was not logged in the centrally stored list which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee to provide training to staff regarding logging medication in centrally stored list and submit proof of training and correction of Log to CCLD by due date.

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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: CHRISTINA'S CARE HOME	FACILITY NUMBER: 107201450
	VISIT DATE: 01/09/2024

NARRATIVE

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one of resident’s medication was not logged. Staff files were reviewed for good health and first aid/CPR. It was verified that there are at least one staff on duty who is CPR certified. Staff files reviewed and complete.

Deficiencies are 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 1/16/2023: 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 LIC9020.

An exit interview was conducted with staff. Report signed on-site; a copy of this report, 809D with appeal rights was provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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