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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206601
Report Date: 06/13/2024
Date Signed: 06/13/2024 10:17:41 AM


Document Has Been Signed on 06/13/2024 10:17 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:A PLACE CALLED HOME RESIDENTIAL CAREFACILITY NUMBER:
107206601
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2827 CALIMYRNA AVETELEPHONE:
(559) 322-4432
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee/Administrator David Murchison TIME COMPLETED:
10:30 AM
NARRATIVE
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On 06/13/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met caregiver John Quinto. LPA toured facility with caregiver. Licensee/Administrator David Murchison was called and arrived later during tour. All six 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. Medications were observed locked in kitchen shelf. MARs were reviewed. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 39 degrees F and freezer at 0 degrees F. Fire extinguisher was observed with a service date of: 02/2024. Cleaning supplies and chemicals stored and locked under kitchen sink. Dryer observed operational during inspection. All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested at 117 degree F in the bathroom 1 and 114.3 degree F in bathroom 2. Extra linens were observed. Outside of facility toured and observed to be free of debris. Adequate outdoor seatings available for residents. Sample of residents’ and staff files were reviewed to have all the required documents.

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

Exit Interview conducted. A copy of this report and appeal rights was provided to Licensee, 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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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 06/13/2024 10:17 AM - 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: A PLACE CALLED HOME RESIDENTIAL CARE
FACILITY NUMBER: 107206601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)(2)
87615 (a)(2) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews conducted, and records reviewed, the licensee did not comply with the section cited above, R1 reside at the facility with no exception for PEG tube feed this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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Licensee is to request for an exception for R1 to Fresno CCL office by POC due date 06/14/24.
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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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