<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201663
Report Date: 10/17/2024
Date Signed: 10/17/2024 04:24:10 PM


Document Has Been Signed on 10/17/2024 04:24 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:SERENITY LIVINGFACILITY NUMBER:
107201663
ADMINISTRATOR:JONES, JOSIANEFACILITY TYPE:
740
ADDRESS:2605 W. BARSTOW AVENUETELEPHONE:
(559) 449-0504
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee, Josiane JonesTIME COMPLETED:
01:01 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 10/17/2024 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Direct Care Staff, Elaine Salcedo LPA introduced self, explained reason for visit and was permitted entry into the facility. Licensee, Josiane Jones was contacted and arrived some time later.

LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas. Currently there are no residents receiving hospice services. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 8/14/24. Last fire drill on 5/26/24. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps were located in locked closet near laundry room. LPA observed sufficient seating under covered patio areas.

The following issues were observed during todays visit: chemicals and items posing a harm to residents in R3's bedroom closet, in the laundry room and in the garage unlocked and accessible to residents in care. Water temperature measured at 129.8 degrees F in the kitchen.

LPA requested the following documents to be submitted to CCL by 10/25/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview completed with Licensee, Josiane Jones. A copy of this report, deficiency and appeal rights provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/17/2024 04:24 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: SERENITY LIVING
FACILITY NUMBER: 107201663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 LPA observation, the licensee did not comply with the section cited above in that the facility was observed with chemicals and items posing a harm to residents in R3's bedroom closet, in the laundry room and in the garage unlocked and accessible to residents in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
1
2
3
4
Items were immediately locked. Licensee will provide all staff training. In-serivce sign in sheets and training material to be provided to CCL by POC date as proof of correction.
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 MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2