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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206609
Report Date: 05/15/2023
Date Signed: 05/15/2023 01:49:59 PM

Document Has Been Signed on 05/15/2023 01:49 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: DATE:
05/15/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:
Elizabeth Dyer, Licensee
Misty Hastings, Daughter In Law
TIME COMPLETED:
11:15 AM
NARRATIVE
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An office meeting for Non-compliance conference was completed this date. The following deficiencies are being issued for the following:

· HSC 1569.58(a)(4) Conduct Inimical - Engaged in any other conduct that would constitute a basis for disciplining a licensee. Based on LPA’s interviews and interactions with licensee, the licensee is uncooperative.
· CCR 87405(d) Administrator - Qualifications and Duties - The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
· CCR 87211(a) Reporting Requirements - Each licensee shall furnish to the licensing agency such reports as the Department may require…based on records reviewed, the facility failed to report incidents of resident’s elopement, AWOL, and hospitalization.

The licensee was uncooperative and did not listen to the issues and refused to sign the report. The Licensee left the meeting and refused to wait for print out of the report. Copies of the report will be emailed to her.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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 05/15/2023 01:49 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 05/15/2023 at 11:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GETTYSBURG CHRISTIAN HOME
FACILITY NUMBER: 107206609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2023
Section Cited

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HSC 1569.58(a)(4) Conduct Inimical - Engaged in any other conduct that would constitute a basis for disciplining a licensee. Based on LPA’s interviews and interactions with licensee, the licensee is uncooperative.


This requirement was not met as evidenced by:
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During the NCC and previous inspections the licensee is uncooperative, argumentative and uses profanity.
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Type B
05/29/2023
Section Cited

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CCR 87405(d) Administrator - Qualifications and Duties - The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

This requirement was not met as evidenced by:
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Based on interviews conducted and observation the licensee is not following applicable rules and regulations.
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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 Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 05/15/2023 01:49 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 05/15/2023 at 11:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GETTYSBURG CHRISTIAN HOME
FACILITY NUMBER: 107206609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2023
Section Cited

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CCR 87211(a) Reporting Requirements - Each licensee shall furnish to the licensing agency such reports as the Department may require…based on records reviewed, the facility failed to report incidents of resident’s elopement, AWOL, and hospitalization.

This requirement was not met as evidenced by:
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Based on records reviewed the department does not have incident reports of residents elopement and hospitalization.
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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 Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
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