107204054-3-9-2023-24-AS-MYAG-CPS2DZ-20230309161909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107204054
Report Date: 03/09/2023
Date Signed: 03/09/2023 04:19:56 PM

Document Has Been Signed on 03/09/2023 04:19 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:	HAPPY LIVING FACILITY		FACILITY NUMBER:	107204054
ADMINISTRATOR:	CATACUTAN, RAQUEL		FACILITY TYPE:	740
ADDRESS:	5275 E. KAVILAND		TELEPHONE:	(559) 441-0351
CITY:	FRESNO	STATE: CA	ZIP CODE:	93725
CAPACITY:	6	CENSUS: 3	DATE:	03/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Licensee Raquel Catacutan		TIME COMPLETED:	04:30 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 3/9/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA was greeted by Licensee and granted entry. LPA introduced self and stated the purpose of the visit. LPA conduct tour with Licensee. All three residents were present during the inspection. The tour started in the common areas into the kitchen to resident's rooms and bathroom. LPA observed COVID-19 related signs. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Medications are kept locked medication kitchen shelf. Cleaning chemicals and sharps are kept in locked under kitchen sink and in laundry cabinet. Refrigerator temperature maintained at 40 degrees F and freezer temperature at 0-degree F. An adequate supply of perishable and non-perishable food was observed to be properly stored. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lightning. Bathrooms were properly equipped, and the hot water temperature was tested at 114.4-degree F. Trash can with lid and hand washing postings was observed. Fire extinguisher was observed with a service date of: 05/14/21. First aid kit was observed and contained all required items. The exterior tour was conducted. LPA and Licensee observed by siding door a table saw covered and an electrical tool unlock. Side gate was self-closing and self-latching. All residents’ file reviewed to have update emergency contacts, Admission agreement, and physician report. A sample of staff files were also reviewed. Staff files were observed to have current First Aid/CPR. Staff are fingerprinted clear and associated to the facility. Carbon monoxide and smoke detectors were tested and observed to be operational.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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 03/09/2023 04:19 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: HAPPY LIVING FACILITY	FACILITY NUMBER: 107204054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when LPA and Licensee observed electric tool and table saw was observed covered by a sheet outside in the backyard near siding door with one ambulatory resident present. Tools were unlocked and accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee shall remove electrical tool and table saw immediately. Proof of correction shall be submitted to CCL by due date 3/10/23.

Type A

Section Cited

CCR

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, Fire Extinguisher has a service date of 05/14/21, which poses an immediate health and safety risk to the residents.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 03/10/23.

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) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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: HAPPY LIVING FACILITY	FACILITY NUMBER: 107204054
	VISIT DATE: 03/09/2023

NARRATIVE

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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: 3/15/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 808, Lic 9282, current liability insurance, and current Administrator certificate. LPA received a copy of facility sketch. A copy of this report and appeal rights was provided to the Licensee.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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