<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206609
Report Date: 03/07/2023
Date Signed: 03/07/2023 01:46:10 PM


Document Has Been Signed on 03/07/2023 01:46 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:GETTYSBURG CHRISTIAN HOMEFACILITY NUMBER:
107206609
ADMINISTRATOR:DYER, ELIZABETHFACILITY TYPE:
740
ADDRESS:4844 E. GETTYSBURGTELEPHONE:
(559) 294-9080
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:18CENSUS: 13DATE:
03/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Licensee Elizabeth Dyer TIME COMPLETED:
02:00 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 3/07/2023, Licensing Program Analysts (LPAs) K.Kaur and K. Brown arrived unannounced and conducted a case management - deficiencies in conjunction with a subsequent complaint visit.

LPAs interviewed Administrator (AD) and reviewed Resident (R1's) facility file. During the interview, AD confirmed that there was no assessment conducted or documents updated prior to R1's return to the facility from the Skilled Nursing Facility (SNF).
1. Appraisal was not conducted prior to readmission to determine needs and level of care
2. The most recent Physician's report obtained is dated 9/11/2019, which indicated R1 is ambulatory
3. There was no needs or services appraisal to review.

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

An exit interview was conducted with Licensee. Report signed on-site by Licensee and printed copy provided with appeal rights.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/07/2023 01:46 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: GETTYSBURG CHRISTIAN HOME
FACILITY NUMBER: 107206609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2023
Section Cited

1
2
3
4
5
6
7
87463 Reappraisals (a) The pre-admission appraisal shall be updated…to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include: (3) Any illness, injury, trauma, or change in the health care needs of the resident…
1
2
3
4
5
6
7
AD has agreed to provide a written statement to include that the regulation has been reviewed and the requirements of resident reappraisal prior to readmission are understood. The written statement will be emailed by the due date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: AD confirmed facility did not conduct a reappraisal or in person assessment of R1 prior to returning to the facility after being treated in SNF. AD stated during an interview that the facility was unable to transfer R1 out of bed upon return from SNF for ADL care. This poses a potential health, safety, or personal rights risks for residents in care.
8
9
10
11
12
13
14
Type B
03/28/2023
Section Cited

1
2
3
4
5
6
7
87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
1
2
3
4
5
6
7
AD agreed to review all resident medical assessments (Physicians Reports) to identify which reports need to be updated based on the regulation stated. AD will provide a copy of the updated reports to CCLD by the due date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

The file review indicated the Licensee had a physician’s order dated 9/11/2019. This poses a potential health, safety, or personal rights risks for residents in care.

8
9
10
11
12
13
14
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) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2