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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107202375
Report Date: 10/26/2022
Date Signed: 10/26/2022 12:13:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/24/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20221024093301
FACILITY NAME:MILLBRAE CARE HOMEFACILITY NUMBER:
107202375
ADMINISTRATOR:ABALOS, CORA MFACILITY TYPE:
740
ADDRESS:1626 W MILLBRAETELEPHONE:
(559) 765-8335
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 3DATE:
10/26/2022
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Administrator, Leticia RodriguezTIME COMPLETED:
12:19 PM
ALLEGATION(S):
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Facility has clutter in front of the heating closet creating a fire hazard.
INVESTIGATION FINDINGS:
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On 10/26/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced Initial 10-day complaint visit. LPA met with Staff, Teresita Flores. LPA introduced self and was permited entry into the facility. LPA was not COVID pre-screened upon entry. Administrator, Leticia Rodriguez was contacted and arrived a short time later. LPA toured facility inside and out. A health and safety check was completed on residents in care. Residents observed in common areas and in room.

During tour of the facility LPA observed three large boxes containing clothes and personal hygeine products next to the heating/cooling unit in the hallway closet. Based on LPA’s interview with Administrator and LPA's observations, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, deficiencies is being cited on the attached LIC 9099D.

Exit interview completed with Director, Reginald Webster. A copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20221024093301
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MILLBRAE CARE HOME
FACILITY NUMBER: 107202375
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (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.
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Administrator will review regulation 87303 to familiarize staff. Laundry baskets to be purchased. Once area clean and free of obstruction Administrator to provide pictures and complete training to staff on regulations. Administrator to provide a sign in sheet/training materials to CCL by POC date.
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This requirement was not met as evidence by: LPA observation and interivew conducted with Administrator. LPA observed three large boxes containing clothes and personal hygeine products next to the heating/cooling unit in the hallway closet.
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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: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
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