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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202375
Report Date: 11/03/2023
Date Signed: 11/07/2023 02:21:26 PM


Document Has Been Signed on 11/07/2023 02:21 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: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: 6DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Administrator, Leticia RodriguezTIME COMPLETED:
01:28 PM
NARRATIVE
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On 11//2023 Licensing Program Analyst (LPA) M. Garza arrived to complete an unannounced annual visit. LPA met with Direct Care Staff, Teresita Flores, explained reason for visit and was permitted entry into the facility. Administrator, Leticia Rodriguez was contacted and arrived some time later.

LPA toured the facility inside and out and completed a health and safety check on residents in care. Residents observed in common areas and in rooms. 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 purchased 6/7/23. Last fire drill on 6/8/23. LPA observed sufficient covered seating in back yard.

During visit the following issues were observed by LPA: Resident room #2 observed with missing dresser, 2 lamps and 2 chairs, Resident room #3 observed to be missing lamp, linens observed to be worn, garage was observed with clutter, 2 of 2 side gates do not open from the inside and are not self latching.

LPA requested the following documents to be submitted to CCL by 11/10/23: 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 Administrator, Leticia. Due to time constraints, LPA will return at a later date for an annual continuation. A copy of this report, deficiencies, TA's and appeal rights will be sent via email.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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 11/07/2023 02:21 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: MILLBRAE CARE HOME
FACILITY NUMBER: 107202375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

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 the portable fireplace gets hot to the touch and is not surrounded by a screen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2023
Plan of Correction
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Administrator stated they would surround with a screen. Proof of correction to be submitted to CCL by picture on or before POC date.
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: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/07/2023 02:21 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: MILLBRAE CARE HOME
FACILITY NUMBER: 107202375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(3)

87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of...

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 Resident room #2 observed with missing dresser, 2 lamps and 2 chairs, Resident room #3 observed to be missing lamp and linens observed to be worn, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2023
Plan of Correction
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Administrator to purchase/provide missing items to residents. Administrator to provide training to all staff. In-serivce sign in sheet and training material to be provided to CCL by POC date.
Type B
Section Cited
CCR
87303(a)

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.

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, which garage was observed with clutter, 2 of 2 side gates do not open from the inside and are not self latching. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Administrator stated garage will be cleaned up with all items posing a danger to residents being made inaccessible/locked. Gates will be fixed and proof of corrections to be sent to CCL by POC date in the form of pictures and/or receipts.
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: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3