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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202381
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:37:03 PM


Document Has Been Signed on 09/04/2024 03:37 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:GIFT OF GRACE CARE HOMEFACILITY NUMBER:
107202381
ADMINISTRATOR:PAMELA LEWISFACILITY TYPE:
740
ADDRESS:1480 W. SAN MADELE AVENUETELEPHONE:
(559) 284-8857
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Administrator, Phoeun MarezTIME COMPLETED:
03:45 PM
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On 9/4/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Care Giver, Josephine Jo and Care Giver, Ryan Figueroe. LPA introduced self, explained reason for visit and was permitted entry into the facility. Administrator, Phoeun Marez was contacted and arrived some time later.

LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There was 1 resident on hospice at the time of the inspection. 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 2/5/24. Last fire drill on 7/1/24. Water temperature measured at 109 degrees F in restroom #1 and 110 degrees F in restroom #2 and kitchen. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps, chemicals located in locked closets/rooms. LPA observed sufficient seating under covered patio areas.

The following issues were observed during time of visit. Chemicals observed unlocked in restroom #1 drawer. Medications observed in lock box unlocked and accessible to residents in care.

LPA requested the following documents to be submitted to CCL by 9/13/24: 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.

Deficiencies cited on 809D. Exit interview completed with Administrator, Phoeun Marez. A copy of this report, deficiencies and appeal rights were provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
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 09/04/2024 03:37 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: GIFT OF GRACE CARE HOME
FACILITY NUMBER: 107202381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
97309(a)
(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. LPA observed chemicals in restroom #1 drawer and medications in refrigerator lock box unlocked and accessible to residents in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Administrator stated that training will be completed with all staff regarding regulation and initiate a lock check log. Administrator will furhter do random surprise checks on staff to ensure they continue to follow regulations and have chemicals and medications locked and inaccessible. Administator to provide training material, sign in sheet and 2 week log to CCL for POC.
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: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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