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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201840
Report Date: 03/29/2023
Date Signed: 03/30/2023 08:34:51 AM

Document Has Been Signed on 03/30/2023 08:34 AM - 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:MARIAN HOMES 3FACILITY NUMBER:
107201840
ADMINISTRATOR:JANARDHAN NAGARAJFACILITY TYPE:
740
ADDRESS:3238 JASMINE AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Sundari "Susan" KendakurTIME COMPLETED:
03:30 PM
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On 3/29/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA arrived and met with Staff Milijaida Roper. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. Administrator Susan Kendakur was called and arrived shortly. LPA toured facility with Administrator. All six residents were present during inspection.

The tour started in the kitchen into the common areas to resident's rooms. LPA observed COVID-19 related signs. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Medications are kept locked medication kitchen shelves. At approximately 01:05 PM, LPA and Administrator observed multiple small roaches in resident’s medication tray and in medication shelf. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 40 degrees F. First aid kit was observed and contained all required items. Fire extinguisher was observed with a service date of: 06/01/23. Last fire drill completed on 01/14/23.



Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. LPA observed 1 shared residents’ bed to be at least 6 feet apart and 4 single occupant room. Bathrooms were properly equipped, and the hot water temperature was tested 116.7 degrees F in shared bathroom and 117.1 degrees F in hall bathroom. Trash can with lid and hand washing postings was observed. Cleaning supplies and chemicals are kept in locked in garage cabinet. Outside of facility toured. Side gate was self-closing and self-latching.

All clients’ file reviewed to have update Emergency contacts, Admission agreement, Pre-Appraisal form, and physician report. A sample of staff's files were also reviewed to have current First Aid/CPR, fingerprinted clear and associated to the facility. Carbon monoxide and smoke detectors were tested and observed to be operational.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: MARIAN HOMES 3
FACILITY NUMBER: 107201840
VISIT DATE: 03/29/2023
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A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 4/4/23. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 9282, control of property, and current Administrator certificate. A copy of this report was provided to the Administrator.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
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Document Has Been Signed on 03/30/2023 08:34 AM - It Cannot Be Edited


Created By: Mai Yang On 03/29/2023 at 02:36 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: MARIAN HOMES 3
FACILITY NUMBER: 107201840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and Administrator toured facility and observed at approximately 01:05PM, multiple small roaches alive in one of the residents medication basket. LPA and Administrator observed small roaches in medication shelf which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2023
Plan of Correction
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Administrator scheduled pest control for 04/03/23 and documentation of a plan in detail of what the facility will have in place for roach preventation. Documentation of plan and pest control service record will be submitted to the department by 4/4/23.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


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