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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202573
Report Date: 11/29/2023
Date Signed: 12/05/2023 04:16:30 PM

Document Has Been Signed on 12/05/2023 04:16 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:REEDLEY HOMEFACILITY NUMBER:
107202573
ADMINISTRATOR:LUPE MARTINEZFACILITY TYPE:
735
ADDRESS:3461 S. USRY AVENUETELEPHONE:
(559) 638-6640
CITY:REEDLEYSTATE: CAZIP CODE:
93654
CAPACITY: 6CENSUS: DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Licensee, Lupe MartinezTIME COMPLETED:
01:05 PM
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On 11/29/23 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA contacted Licensee, who arrived some time later. LPA was met by with Licensee, Lupe Martinez, Administrator, Dale Martinez and Direct Care Staff, Kyrstyn Martinez, introduced self, explained reason for visit and was permitted entry into the facility. Facility is currently being renovated in the kitchen, dining room and right side bedroom areas.

LPA toured the facility inside and out. 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 5/26/23. Last fire drill on 10/28/2023. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closet in restroom and linen closet in back bedroom. Sharps and medications were located in locked cabinets.

The following issues were observed during visit: Chemicals observed in open storage room, storage shed with tools was unlocked and accessible, window screens in front of homewindow coverings in need of replacement, side door in need of molding, bedroom #3 observed with a soiled mattress in need of replacement, bedroom #4 dresser observed with drawers that did not properly open and close, bathroom #2 observed with wood rot in baseboard near shower, water temperature measured at 121.8 in bathroom #2, pool gate is locked but in need of repair.

LPA requested the following documents to be submitted to CCL by 12/06/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Deficiencies cited on 809D per Title 22. TA provided for water temperature. Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed. A copy of this report appeal rights and TA provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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 12/05/2023 04:16 PM - It Cannot Be Edited


Created By: Mary Garza On 11/29/2023 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: REEDLEY HOME
FACILITY NUMBER: 107202573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, 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 Chemicals observed in open storage room, storage shed with tools was unlocked and accessible, window screens in front of homewindow coverings in need of replacement, side door in need of molding, bedroom #3 observed with a soiled mattress in need of replacement, bedroom #4 dresser observed with drawers that did not properly open and close, bathroom #2 observed with wood rot in baseboard near shower, pool gate is locked but in need of repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Licensee will provide receipts and pictures of the corrections once completed by 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 Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
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