107206271-8-22-2023-24-AS-MYAG-CUY4DE-20230822190038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206271
Report Date: 08/22/2023
Date Signed: 08/22/2023 07:00:43 PM

Document Has Been Signed on 08/22/2023 07:00 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:	AUTUMN RIDGE ASSISTED LIVING		FACILITY NUMBER:	107206271
ADMINISTRATOR:	JAIME, MORY		FACILITY TYPE:	740
ADDRESS:	14280 W. STANISLAUS STREET		TELEPHONE:	(559) 842-7727
CITY:	KERMAN	STATE: CA	ZIP CODE:	93630
CAPACITY:	34	CENSUS: 22	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Administrator Mory Jaime		TIME COMPLETED:	07:15 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 08/22/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator (ADM) Mory Jaime. LPA conducted tour of facility with ADM. Residents were observed seating in lobby upon LPA arrival. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 06/23/23. Medications were stored in medication cart in locked medication room. MARs and medications were reviewed. Activity room, conference room, and facility beauty salon was toured. LPA toured 09 out of 27 rooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lightning. Bathroom was toured and observed to be operational. LPA observed securely fastened grab bars and non-skid mat in all tub/shower areas. Hot water temperature was tested range between 105 to 105.2 degrees F in residents’ bathrooms. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored. Temperature was maintained at 34 degree F. in refrigerator 1 and maintained at 39 degrees F in refrigerator 2. Freezer temperature was maintained at 0 degree F. Chemicals was stored and locked in housekeeping closet. The outside was toured and observed to be free from debris. There was outdoor seating available for the residents in courtyard.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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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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: AUTUMN RIDGE ASSISTED LIVING	FACILITY NUMBER: 107206271
	VISIT DATE: 08/22/2023

NARRATIVE

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A deficiency is being cited on the attached Lic 809D in accordance with California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. The following documents are requested and submitted to
Fresno CCL by: 08/28/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, current Administrator certificate, and current liability insurance. A copy of this report and appeal rights was given to Administrator, whose signature on this form confirm receipt of these reports.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2023 07:00 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: AUTUMN RIDGE ASSISTED LIVING	FACILITY NUMBER: 107206271
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed and interview, LPA reviewed files for all five staff working during inspection. Records shown S1 have First Aid and CPR with an expiration date of 09/29/2019. Four out of five staff did not have First Aid/ CPR certification. Administrator confirmed that all five staff on duty did not have First Aid/ CPR certification which possess an immediate health and safety and personal rights risk to the clients in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Proof of current CPR certification for all five staff working during inspection shall be submitted to the department by 08/23/23. Licensee shall ensure that at least one staff member during each shift is CPR certified and trained.

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) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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