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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202381
Report Date: 11/01/2023
Date Signed: 11/01/2023 12:52:34 PM


Document Has Been Signed on 11/01/2023 12:52 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: 6DATE:
11/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Administrator, Phoeun MarezTIME COMPLETED:
12:55 PM
NARRATIVE
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On 11/1/2023 Licensing Program Analyst (LPA) M. Garza arrived to complete an unannounced annual visit. LPA met with Administrator, Phoeun Marez explained reason for visit and was permitted entry into the facility.
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. 4 of 6 residents on hospice at time of visit. 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 7/11/23. Last fire drill on 9/4/23. Resident rooms observed to have the required furnishings and with adequate lighting. LPA observed sufficient covered seating in back yard.

During visit the following issues were observed by LPA: Chemicals observed in bathroom #1 under sink, in bathroom #2 on counter tops, in the hallway cabinets, outside storage shed and in water heater closet unlocked and accessible. Medications observed in laundry room cabinet unlocked and accessible to residents. Water temperature measured at 122.2.

LPA requested the following documents to be submitted to CCL by 11/8/23: 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.

Deficiencies cited during the inspection. Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with Administrator, Phoeun Marez. A copy of this report and appeal rights given.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
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 3


Document Has Been Signed on 11/01/2023 12:52 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: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 water temperature was observed to be at 122.2 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Water heater immediately lowered. Administrator stated they will complete a two-week water temperature log. Water temperatrues will be taken 2x daily and will be submitted to CCL.
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 chemicals observed in bathroom #1 under sink, in bathroom #2 on countertops, in the hallway cabinets, outside storage shed and in water heater closet. All were unlocked and accessible to residents in care.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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Administator will generate a log for staff initials stating they are checking to make sure the locks are being used. Training will be provided to all staff. In-service sign in sheet and training material will be provided 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: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/01/2023 12:52 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: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 medications observed in laundry room cabinet unlocked and accessible to residents. 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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Administator will generate a log for staff initials stating they are checking to make sure the locks are being used. Training will be provided to all staff. In-service sign in sheet and training material will be provided to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3