107201595-7-18-2023-24-AS-MTHO-CTUVMC-20230718163320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201595
Report Date: 07/18/2023
Date Signed: 07/18/2023 04:33:40 PM

Document Has Been Signed on 07/18/2023 04:33 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:	HULBERT AVENUE CHRISTIAN HOME		FACILITY NUMBER:	107201595
ADMINISTRATOR:	FERNANDEZ, NARCISA		FACILITY TYPE:	740
ADDRESS:	4473 N. HULBERT AVENUE		TELEPHONE:	(559) 246-5637
CITY:	FRESNO	STATE: CA	ZIP CODE:	93705
CAPACITY:	6	CENSUS: 3	DATE:	07/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Narcisa Fernandez, Licensee/Administrator		TIME COMPLETED:	04:55 PM

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On 7/18/23 at 1:28 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. LPA met with Licensee/Administrator (LIC) Narcisa Fernandez.

Facility was toured with ADM. Smoke detector tested and operational. Bedrooms were checked. Centrally stored medication observed in locked kitchen cabinet. Food supply was observed in adequate supply. Cleaning supplies observed in locked garage. Staff and resident records reviewed. Administrator certification is valid.

The following deficiencies were observed:
1. Hot water in hall bathroom measured at 124.8 degrees F.
2. No carbon monoxide detector was installed in the facility.
3. Can of Comet and powdered detergent observed in accessible cabinet under kitchen sink.

Deficiencies are being cited based on LPA observation and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were given to Licensee, whose signature on this form confirms receipt of these documents.

The following updated forms are to be submitted to CCL within 2 weeks:

LIC610E, LIC500, LIC9020, Proof of liability insurance, LIC308

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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 07/18/2023 04:33 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HULBERT AVENUE CHRISTIAN HOME	FACILITY NUMBER: 107201595
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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. No carbon monoxide detector was installed in the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of carbon monocide detector installed and operational, to CCL by POC due date.

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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. Can of Comet and powdered detergent observed in accessible cabinet under kitchen sink, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2023
	Plan of Correction
1 2 3 4	Licensee immediately removed the Comet and powdered detergent to the locked and inaccessible garage. POC cleared during the inspection.

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 Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 04:33 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: HULBERT AVENUE CHRISTIAN HOME	FACILITY NUMBER: 107201595
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). 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. Hot water in hall bathroom measured at 124.8 degrees F, which poses an immediate safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of hot water in hall bathroom measuring within 105-120 degrees F, to CCL by POC 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: Melinda Hoffmann	TELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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