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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202377
Report Date: 05/13/2024
Date Signed: 05/13/2024 03:46:11 PM

Document Has Been Signed on 05/13/2024 03:46 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:MONSEVAIS RES. FACILITY, INC.-DEWEY HOMEFACILITY NUMBER:
107202377
ADMINISTRATOR/
DIRECTOR:		MONSEVAIS, LYNEILFACILITY TYPE:
735
ADDRESS:6714 N. DEWEYTELEPHONE:
(559) 447-8680
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 5CENSUS: 4DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:51 AM
MET WITH:Care Staff, Stanley ThomasTIME VISIT/
INSPECTION COMPLETED:
01:49 PM
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On 5/13/2024 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Direct Care Staff, Stanley Thomas. LPA introduced self, explained reason for visit and was permitted entry into the facility. Licensee was contacted and stated they were unavailable to come to the facility. Licensee provided permission to complete visit with Direct Care Staff, Stanley.

LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. 2 of 4 residents present during visit. Residents observed in common areas and in backyard. 2 of 4 residents attending day program. Pathways and doors were clear and free from obstruction inside facility. Common areas were adequately furnished, and adequately lit. Smoke detectors detectors were present and operational at time of visit. Fire extinguisher last purchased 4/23/24. 1 of 4 resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps, chemicals and medications were located in locked closets/rooms. LPA observed sufficient seating under covered patio area.

The following issues were observed during visit: Facility is in need of general housekeeping. Facility observed with overbearing odor of cigarette smoke. Broken tile in walkway to front living room. Facility observed with flies. Food in refrigerator/freezer was improperly stored/missing dates. Freezer door broken inside. Kitchen drawers/cabinets off track/not closing properly. Wood rot under kitchen sink cabinet. Tile missing in kitchen. Flooring in living/dining area lifting. Chemicals observed under kitchen sink/cabinets/in garage.

CONT...
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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
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: MONSEVAIS RES. FACILITY, INC.-DEWEY HOME
FACILITY NUMBER: 107202377
VISIT DATE: 05/13/2024
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CONT...

Garage door spring broken and door non-functioning. Garage door blocked with reclining chair and unable to access.Garage wall has hole. Garage freezer needs to be defrosted. Living/Dining area couches in need of replacement (worn/torn). Bedroom #1 light not functioning and dresser not in good repair (missing handles on drawers). Holes in bedroom #2 closet, missing lamp, chair and dresser drawers off tracks. Bedroom #3 holes in wall and missing lamp. Bedroom #4 observed with no lamp, chair and closet light not functioning. Bathroom #1 has toilet tile loose. Snack closet observed with opened cookies improperly stored. Bedroom #5/Storage room observed with items/trash under sink cabinet. Outside facility paint chipping and in need of removal. Wood beams observed with wood rot in back yard. Right side gate does not open/close properly.

LPA requested the following documents to be submitted to CCL by 5/20/24: 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.

Licensee will be scheduled for an in office meeting and deficiencies will be cited at this time. Exit interview completed with Direct Care Staff, Stanley. A copy of this report was emailed as requested by Licensee. A delivered and read receipts serves as confirmation.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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