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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202374
Report Date: 06/03/2024
Date Signed: 06/03/2024 01:22:43 PM


Document Has Been Signed on 06/03/2024 01:22 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:NEW LIGHT RESIDENTIAL CARE HOME, THEFACILITY NUMBER:
107202374
ADMINISTRATOR:GALVEZ, MARLENEFACILITY TYPE:
740
ADDRESS:1322 W. ROBERTS AVE.TELEPHONE:
(559) 261-9818
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 6DATE:
06/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Administrator, Carlo SantosTIME COMPLETED:
01:32 PM
NARRATIVE
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On 6/3/24 Licensing Program Analyst (LPA) M. Garza and Licensing Program Manager (LPM) , S. Moua arrived unannounced for an annual inspection visit. LPA was met by Direct Care Staff, Joseph and Bae Chua. LPA and LPM introduced selves, explained reason for visit and were permitted entry into the facility. Designee, Carlo Santos was contacted and arrived some time later. A health and safety check on residents in care was completed. 4 of 5 residents present at time of visit. Residents observed in common areas and in rooms.

Facility was toured inside and out. 2 of 6 residents currently 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 9/6/23. Last fire drill on 2/21/24. Water temperature measured 114.8 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps and medications were located in locked cabinet/closet. LPA observed seating under covered patio areas. The following issues were observed during the visit: kitchen cabinets/drawers off track/broken and in need of repair, back sliding door not properly opening/closing, R5 was observed with hospital bed without a prescription, chemicals observed in R1's bathroom unlocked and accessible to residents in care.

LPA requested the following documents to be submitted to CCL by 6/10/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Deficiencies cited per Title 22. Exit interview completed with Designee, Carlo Santos. A copy of this report, deficiencies, TV's and appeal rights provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
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 06/03/2024 01:22 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: NEW LIGHT RESIDENTIAL CARE HOME, THE
FACILITY NUMBER: 107202374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

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
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Based on LPA observation, the licensee did not comply with the section cited above in that R1's bathroom was observed with chemicals unlocked and accessible to residents in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2024
Plan of Correction
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Installation of a lock on bathroom cabinet to place personal hygeine/chemicals into. Training with staff and residents to utilize this to keep all products locked and inaccessible to other residents in care. Picture of lock once installed will be provided to CCL by POC date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations it was observed that R5 had 1/2 bed rails. During review of R5's file it was observed that R5 did not have a physicians prescription for the rails. CCL does not have an exception on file for R5. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2024
Plan of Correction
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Facility will obtain physicians order for bed rails. Precription and exception request will be submitted to CCL by POC 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 MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/03/2024 01:22 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: NEW LIGHT RESIDENTIAL CARE HOME, THE
FACILITY NUMBER: 107202374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations the back sliding door exiting off the living room does not properly open/close or is broken and in need of repair. Kitchen cabinets/drawers are off track or in need of repair and do not open/close properly. These pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2024
Plan of Correction
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Facility is a rental and will notify landlord of issues. Facility will work with landlord to repair door and cabinets. If not fixed within 1 week facility will notify CCL with an anticipated fix date. Pictures or video for corrections will be provided to CCL by POC date or extension requested.
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 MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
LIC809 (FAS) - (06/04)
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