107201451-1-29-2024-24-AS-KKAR-CZXUVV-20240129145545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201451
Report Date: 01/29/2024
Date Signed: 01/29/2024 02:57:24 PM

Document Has Been Signed on 01/29/2024 02:57 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 II		FACILITY NUMBER:	107201451
ADMINISTRATOR:	STEPHEN, RAVI		FACILITY TYPE:	740
ADDRESS:	1910 INDIANAPOLIS AVENUE		TELEPHONE:	(559) 347-9900
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 6	DATE:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Ravi Stephen, Licensee/Administrator		TIME COMPLETED:	03:30 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 1/29/2024, 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 Gilbert Goyal. Licensee /Administrator was contacted and arrived a short time later. LPA toured the facility with the staff. Tour started at the facility kitchen. 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. LPA observed 7-day supply of non-perishable foods and 2-day supply of perishable foods. The fire extinguisher in kitchen was serviced 4/21/2023. The dining room is equipped with a table and chairs, the living room is equipped with adequate sofas and recliners for seating. 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 105 degrees F. At 10:45 AM LPA observed in a resident bedroom; a window screen that was torn. LPA observed grab bars installed by toilet and non-skid mats in place. Smoke alarm detectors and Carbon monoxide detectors installed and operational. Adequate outside space for rest and recreational. Sufficient seating observed under covered patio. At 12:20 PM LPA observed outside exit gate was locked with a padlock from the outside. Backyard gate is self-closing and self-latching. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report and ID Documentation. Staff files were reviewed for good health. It was verified that current staff on duty is CPR certified. Last Fire Drill conducted on 1/20/2024. Continued to 809C…

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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 01/29/2024 02:57 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 II	FACILITY NUMBER: 107201451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 the ouside exit gate was locked with a padlock which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Staff removed the padlock during inspection. Licnesee to ensure backyard gate is not locked in the future

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: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/29/2024 02:57 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 II	FACILITY NUMBER: 107201451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. 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 window screen observed with a tear which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/05/2024
	Plan of Correction
1 2 3 4	Licensee to repair/replace and submit pictures of the repaired screen or receipt/invoice of purchase 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: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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 II	FACILITY NUMBER: 107201451
	VISIT DATE: 01/29/2024

NARRATIVE

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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 2/5/2023: 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. Immediate Civil penalty assessed. 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: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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