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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203409
Report Date: 10/11/2023
Date Signed: 10/11/2023 11:29:35 AM

Document Has Been Signed on 10/11/2023 11:29 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:BAGHETTI-HOMEFACILITY NUMBER:
107203409
ADMINISTRATOR:BAGHETTI-ESCALANLE,ROXANNAFACILITY TYPE:
735
ADDRESS:2737 NORWICH AVENUETELEPHONE:
(559) 346-1232
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Licensee Roxanne Baghetti-EscalanleTIME COMPLETED:
11:35 AM
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On 10/11/23, Licensing Program Analyst (LPA) M. Yang and L. Padgett arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit and request to meet with Administrator. LPA met with caregiver Olga Lopez and toured facility. Licensee Roxanne Baghetti-Escalanle was called and arrived shortly during tour. Two clients were present upon arrival and left during inspection to day program.

The facility was observed to be at a comfortable temperature of 74 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Temperature maintained for refrigerator at 37 degrees F and freezer at 0 degrees F. An adequate supply of perishable and non-perishable food was observed. Fire extinguisher was observed with a service date of: 01/11/2023. Cleaning supplies and chemicals stored and locked in laundry closet. Laundry detergent were observed unlock under laundry sink and in the garage. At approximately 09:04AM, LPA and staff observed bug spray and garden tool unlock in the garage.

Fire drill last completed: 07/03/23. All bedrooms were observed to have required furnishings and with adequate lightening. LPA observed two single occupant bedroom and 1 shared bedroom. Bathrooms were properly equipped, and the hot water temperature was tested range 113.5 and 113.9 degrees in master bathroom and range 118.9 and 114.1 degrees F in bathroom 1. Medications observed kept locked in kitchen shelf. MARs were reviewed.

Outside of facility toured and observed to be free of debris. Adequate outside seatings observed available for clients. Side gate observed self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ file reviewed to have update emergency contacts, Admission agreement, and IPP. Staff files were also reviewed. Staff files were observed to have current First Aid/CPR, fingerprinted clear and associated to the facility.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: BAGHETTI-HOME
FACILITY NUMBER: 107203409
VISIT DATE: 10/11/2023
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A deficiency is being cited on the attached 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: 10/17/23. Forms requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610D, control of property, and current Administrator certificate. A copy of this report and appeal rights was provided to the Licensee whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
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Document Has Been Signed on 10/11/2023 11:29 AM - It Cannot Be Edited


Created By: Mai Yang On 10/11/2023 at 10:54 AM
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: BAGHETTI-HOME
FACILITY NUMBER: 107203409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 (g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 observation, the licensee did not comply with the section cited above when LPA and staff observed at approximately 09:02AM, laundry detergent under laundry sink in the laundry room. At approximately 09:04AM, LPA and staff observed bug spray and garden tool unlock in the garage. Two ambulatory client were present during observation when the chemicals were unlocked and accessible to clients in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2023
Plan of Correction
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Staff immediately removed the chemicals and locked in laundry closet. POC cleared during visit.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


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