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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206629
Report Date: 03/23/2023
Date Signed: 03/23/2023 05:14:52 PM


Document Has Been Signed on 03/23/2023 05:14 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:ELIM PLACEFACILITY NUMBER:
107206629
ADMINISTRATOR:WOLF, RACHEL E.FACILITY TYPE:
740
ADDRESS:1808 5TH STREETTELEPHONE:
(559) 875-7268
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY:44CENSUS: 30DATE:
03/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Administrator, Maria CeballosTIME COMPLETED:
05:26 PM
NARRATIVE
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On 3/23/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility for a case management visit. LPA met with Administrator, Maria Ceballos introduced self, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms.

During a previous complaint visit made on 1/28/2023 LPA observed the following: 5 of 6 bedrooms checked were observed to be locked with residents inside. This poses an immediate health, safety or personal rights risk to residents in care. LPA observed resident in room #18 was restrained with a sheet wrapped around legs preventing resident from getting out of bed without assistance. This poses an immediate health, safety or personal rights risk to residents in care. LPA observed 3 of 4 restrooms unlocked with chemicals inside and accessible to residents in care. This poses a potential health, safety or personal rights risk to residents in care.

Deficiencies cited on 809D

Exit interview completed with Administrator, Maria. A copy of this report and appeal rights given.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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 3


Document Has Been Signed on 02/28/2024 01:40 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/28/2024 01:37 PM

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: ELIM PLACE
FACILITY NUMBER: 107206629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited
CCR
87468.1(a)(6)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:...(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night…
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Administrator stated they will provide POC plan via email by 3/24/23. Facility to provide training on regulation. Traiining material and in service sign in sheet will be submitted to CCL by POC date.
***Dismissed & Cleared***
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Thie requirement was not met as evidence by: LPA observation of 5 of 6 bedrooms checked were observed to be locked with residents inside. This poses an immediate health, safety or personal rights risk to residents in care.
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Type A
03/24/2023
Section Cited
CCR87608(5)

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87608 Postural Supports (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet…
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Administrator stated they will provide POC plan via email by 3/24/23. Faciility to provide training on regulation. Traiining material and in service sign in sheet will be submitted to CCL by POC date.
***Dismissed and cleared***
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This requirement was not met as evidence by: LPA observed resident in room #18 was restrained with a sheet wrapped around legs preventing resident from getting out of bed without assistance. This poses an immediate health, safety or personal rights risk to residents in care.
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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: Brenda WhiteTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: See MouaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/23/2023 05:14 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: ELIM PLACE
FACILITY NUMBER: 107206629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Per Administrator facility to provide training on regulation. Traiining material and in service sign in sheet will be submitted to CCL by POC date.
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This requirement was not met as evidence by: LPA observation. LPA observed 3 of 4 restrooms unlocked with chemicals inside and accessible to residents in care. This poses a potential health, safety or personal rights risk to residents in care.
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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) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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