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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202867
Report Date: 05/31/2024
Date Signed: 05/31/2024 01:21:48 PM


Document Has Been Signed on 05/31/2024 01:21 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:MARIAN HOMES 4FACILITY NUMBER:
107202867
ADMINISTRATOR:SUNDARI SUSAN KENDAKURFACILITY TYPE:
740
ADDRESS:2542 FILBERT AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:LuiJean “Jean” DeCastro, Designated Representative TIME COMPLETED:
12:00 PM
NARRATIVE
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On 05/31/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA met with staff Rogelio Canchela. LPA introduce self, stated the purpose of the visit and request to meet with Administrator. Administrator was called and Designee (D1) Shannon Steel arrived shortly and conducted tour with LPA. Designee 2 (D2) LuiJean “Jean” DeCastro arrived later during tour. All four residents were present during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. Temperature maintained for refrigerator at 28 degrees F and freezer at 0 degrees F. Fire extinguisher was observed with a service date of: 06/8/23. Cleaning supplies and chemicals stored and locked under kitchen sink. Knives observed stored and lock under kitchen counter.

Medications observed kept locked in kitchen shelf. Medications and MARs were reviewed. All bedrooms were observed to have required furnishings and with adequate lightening. Bathrooms were properly equipped, and the hot water temperature was tested at 109.7 and 107.2 degrees in bathroom 1 and tested between 110.8 and 110.5 degrees F in shared master bathroom. Outside of facility toured and observed to be free of debris. Adequate outside seatings observed available for residents. Side gate observed self-closing and self-latching.Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ and sample of staff files reviewed to have all the required documents.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 06/06/24. Forms requested: Lic 308, Lic 500, Lic 610E, current liability insurance and current Administrator certificate. A copy of this report and appeal rights was provided to D2, whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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 05/31/2024 01:21 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: MARIAN HOMES 4
FACILITY NUMBER: 107202867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87628(a)
The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when unskilled professional staff confirms administering resident insulin through injections and performing resident’s glucose testing for resident daily, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2024
Plan of Correction
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Licensee will ensure that effective immediately only an RN or skilled professional administer insulin and staff is to assist resident with glucose testing for residents who is unable to independently do so. A written plan of correction is to be submitted to CCL by 06/01/24. A Care Plan for Allowable Health Conditions of R1’s Diabetes is to by submitted to the department by 06/13/24.
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) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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