107203982-7-15-2024-24-AS-KKAR-D77VEQ-20240715162244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107203982
Report Date: 07/15/2024
Date Signed: 07/15/2024 04:23:05 PM

Document Has Been Signed on 07/15/2024 04:23 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:	SHINING LIGHT RCFE, THE		FACILITY NUMBER:	107203982
ADMINISTRATOR:	GALVEZ, DELIA		FACILITY TYPE:	740
ADDRESS:	2749 W. SAN CARLOS AVENUE		TELEPHONE:	(559) 449-0410
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY:	6	CENSUS: 5	DATE:	07/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Designee Administrator Carlo Santos		TIME COMPLETED:	04:45 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 7/15/2024 Licensing Program Analyst (LPA) K.Kaur arrived at facility unannounced to complete an Annual inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Direct Care Staff. Designee Administrator Carlo Santos was contacted and arrived a short time later. The facility has 5 residents, of which all were present during the inspection. LPA toured the facility with the staff. Facility postings observed at entry. Tour started at Bedroom # 1. Fire extinguisher did not have a service date. Tour continued down the hallway and observed two staff rooms. Two Bathrooms toured LPA observed grab bars installed by toilet and showers and non-skid mats in place. Three additional resident rooms toured at the end of the hallway. Residents' bedrooms were observed to be adequately furnished with beds, dresser, and adequate lighting. Mattresses and linen were in good condition. The dining room is equipped with a table and chairs, the living room is equipped with adequate sofas and recliners for seating. Extra linen and towels are available in the hallway closet. Knives were locked in the kitchen cabinet. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods. Medications, first aid kit observed locked in cabinet in kitchen area. Cleaning supplies observed locked in the cabinet next in the laundry cabinets. The laundry area toured and observed with locks on all cabinets. Bedroom # 5 toured next to laundry and garage. Garage observed with locked cabinets for chemicals. Smoke alarm detectors and Carbon monoxide detectors installed and operational. Adequate outside space for rest and recreational. Sufficient seating observed under a covered patio. Backyard gate is self-closing and self-latching. Resident's records contained signed Admission Agreement, Personal Rights, and Physician's Report and ID Documentation. All residents Physician's Report were two to four years old. During Medication review LPA observed Centrally Stored Medication and destruction record (CSMDR) was incomplete. PRN medication that came with resident was not logged in CSMDR. Residents’ response to PRN medication was not noted. Staff files were reviewed for good health. Staff files had health screenings/ TB Clearance. It was verified that current staff on duty are CPR certified. Last Fire Drill conducted on 4/10/2024. Continued to 809C...

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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 07/15/2024 04:23 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: SHINING LIGHT RCFE, THE	FACILITY NUMBER: 107203982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(3)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 5; Medication was not logges in Centrally Stored Log and Residents Response was not recorded which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2024
	Plan of Correction
1 2 3 4	Administrator to submit a statement of intent to provide in service training for PRN medication by due date. Once training is completed; documentation of training needs to be submitted.

Type A

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 Dementia residents did not have a current Medical Assessment which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2024
	Plan of Correction
1 2 3 4	Administrator to schedule doctors’ appointments and submit information to CCLD by due date. Once visit is completed; Administrator to submit copies of 602 to Licensing.

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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC809 (FAS) - (06/04)

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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: SHINING LIGHT RCFE, THE	FACILITY NUMBER: 107203982
	VISIT DATE: 07/15/2024

NARRATIVE

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Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22 Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 7/22/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with appeal rights were provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/15/2024 04:23 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: SHINING LIGHT RCFE, THE	FACILITY NUMBER: 107203982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1; Fire Extinguisher service date or purchase date could not be verfied which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2024
	Plan of Correction
1 2 3 4	Administrator states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the due date.

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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC809 (FAS) - (06/04)

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