<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202784
Report Date: 12/12/2023
Date Signed: 01/04/2024 09:23:11 AM

Document Has Been Signed on 01/04/2024 09:23 AM - 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:OHANNESIAN HOME #2FACILITY NUMBER:
107202784
ADMINISTRATOR:MATTHEW, VERONICAFACILITY TYPE:
735
ADDRESS:10650 SO. FRANKWOOD AVENUETELEPHONE:
(559) 638-2392
CITY:REEDLEYSTATE: CAZIP CODE:
93654
CAPACITY: 6CENSUS: 4DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Administrator, Veronica MatthewTIME COMPLETED:
04:17 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/12/23 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA contacted Administrator, Veronica Matthew. LPA introduced self, explained reason for visit and was informed it would take some time to arrive. LPA was met by Administrator some time later and was permitted entry into the facility.

LPA completed a health and safety check on residents in care. LPA was informed by Administrator residents were at day program during time of visit. LPA toured the facility inside and out. Pathways and doors were clear and free from obstruction. Facility was tidy. Common areas were clean, adequately furnished, and adequately lit. 1 smoke detector was present and operational at time of visit. Fire extinguisher last purchased 8/16/23 and okay. Last fire drill on 11/20/23. Water temperature measured 119.8 degrees F. 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 inside kitchen cupboards.

During visits the following issues were observed: A smell of gas was observed upon entry to the facility. Smoke detectors not observed in all common areas. No carbon monoxide detector present during time of visit. Facility has physical plant issues that will need to be addressed. Facility is a historic home and will be pending city contact. .

LPA requested the following documents to be submitted to CCL by 12/19/23: 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.

Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with Administrator, Veronica Matthew. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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 2
Document Has Been Signed on 01/04/2024 09:23 AM - It Cannot Be Edited


Created By: Mary Garza On 12/12/2023 at 02:27 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: OHANNESIAN HOME #2
FACILITY NUMBER: 107202784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in the facility did not have a carbon monoxide detector at the time of the visit. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
1
2
3
4
Administrator will purchase carbon monoxide detector and installed by POC date. Pictures of detector and receipts will be provided to CCL for verification.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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 Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2