107206629-3-19-2024-24-AS-KKAR-D3HVGJ-20240319162538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206629
Report Date: 03/19/2024
Date Signed: 03/19/2024 04:27:42 PM

Document Has Been Signed on 03/19/2024 04:27 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 PLACE		FACILITY NUMBER:	107206629
ADMINISTRATOR:	WOLF, RACHEL E.		FACILITY TYPE:	740
ADDRESS:	1808 5TH STREET		TELEPHONE:	(559) 875-7268
CITY:	SANGER	STATE: CA	ZIP CODE:	93657
CAPACITY:	44	CENSUS: 28	DATE:	03/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Licensee Rachel Wolf		TIME COMPLETED:	04:45 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 3/19/2024 Licensing Program Analyst (LPA) K.Kaur arrived unannounced for an annual inspection visit. LPA was met by Administrator, Maria Ceballos. LPA introduced self, explained reason for visit and was permitted entry into the facility. Licensee Rachel Wolf arrived a short time later. LPA toured the facility with the Administrator. All pathways, entrances and exits were clear from obstruction. LPA toured locked housekeeping room, and laundry room. LPA observed facility common areas were furnished with sufficient seating. The tour continued to the facility dining room and facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods. Residents observed in common areas and in rooms. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. At 11:49 AM LPA observed in Room # 22 window seal that was broken and decaying. Fire extinguishers observed throughout the facility with service date of 10/17/2023. Bathrooms were properly equipped with non-slip mats and grab bars. At 12:03 PM LPA observed broken tile in one of the bathrooms. The broken tile had black like appearance in the cracks. Black appearance was also visible along the grout lines. LPA observed dust and debris buildup on bathroom fan vent. At 12:14 PM LPA observed a staff office to be unlocked which contained disinfectants and cleaning supplies. Hot water temperature was tested between 105 degrees F and 120 degrees in several restrooms. Carbon monoxide detector tested and. LPA observed delayed egress doors. Facility observed with a signal system. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. Cleaning supplies and chemicals are kept locked maintenance room. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22,Division 6.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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 03/19/2024 04:27 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: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3; LPA observed broken tile in the shower with black appearance, broken window seal which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2024
	Plan of Correction
1 2 3 4	Licensee to repair or replace broken window seal and schedule a assessment for the broken shower tile for mold by due date and repair/replace as needed and submit pictures/ Invoice copies to CCLD when completed.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 staff Office door was left ajar from the patio. Office contained Disinfectant and cleaning supplies which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2024
	Plan of Correction
1 2 3 4	Staff locked office door. Citation cleared during inspection.

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) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

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
	VISIT DATE: 03/19/2024

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LPA is requesting the following documents be submitted to the Fresno CCL office by 3/26/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with Licensee, Rachel Wolf. Report signed on-site; a copy of this report, 809D with appeal rights was provided via email due to technical difficulties.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

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