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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206669
Report Date: 12/16/2022
Date Signed: 12/16/2022 10:23:16 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20220725085334
FACILITY NAME:MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCEFACILITY NUMBER:
107206669
ADMINISTRATOR:MEDINA, MYSTI & ARMANDOFACILITY TYPE:
735
ADDRESS:1354 RAMONA AVE.TELEPHONE:
(559) 292-4183
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:6CENSUS: 4DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
03:14 PM
MET WITH:Administrator, Mysti MedinaTIME COMPLETED:
03:56 PM
ALLEGATION(S):
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Chemicals are accessible to residents in care
Facility dryer being in disrepair
Staff smoke cigarettes on the facility property
INVESTIGATION FINDINGS:
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On 12/15/2023 Licensing Program Analyst (LPA) NM. Garza arrived at facility to deliver findings on the above allegations. Administrator was contacted and arrived a short time later. LPA met with Administrator, Mysti Medina and explained reason for visit. LPA was permitted entry into the facility but was not COVID prescreened. A Health and Safety check was completed on residents in care. Residents observed in common areas and in rooms.

During the investigation documents were requested and reviewed, interviews were completed.

Allegation: Chemicals are accessible to residents in care
During visit on 7/27/2022, LPA observed laundry closet to be unlocked and open. Chemicals being accessible to clients in care. Administrator interview acknowledged this had been discussed on past visit.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20220725085334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCE
FACILITY NUMBER: 107206669
VISIT DATE: 12/16/2022
NARRATIVE
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Allegation: Facility dryer being in disrepair
During visit on 7/27/2022, LPA observed the dryer at the facility to be non-functioning. During interview with Administrator, they advised LPA the dryer had not been functioning for a few weeks. LPA reviewed receipt and picture provided from Administrator showing a new dryer was purchased due to the current one not functioning.

Allegation: Staff smoke cigarettes on the facility property
During visit on 7/27/2022, upon arrival at facility, LPA observed Administrator to be standing in the front yard smoking a cigarette. The front door of the facility was observed to be ajar and the smell of smoke lingered in the facility upon entry.

Based on information provided through LPA observation, documentation and interviews, the allegations listed above are SUBSTANTIATED. A substantiated finding means that there is preponderance of evidence to prove that the allegation occurred. Per California Code of Regulations, Title 22, deficiencies cited on LIC 809D.

An exit interview conducted with Administrator, Mysti Medina. A copy of this report and appeal rights given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20220725085334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCE
FACILITY NUMBER: 107206669
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2023
Section Cited
CCR
80087(g)
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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Administrator to provide training to all staff and generate a check off list of daily duties. Training materials and sign in sheet will be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA observation of laudry closet being unlocked and accessible to clients in care. This poses a potential health, safety and/or personal rights risk to residents in care.
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Type B
01/02/2023
Section Cited
CCR
85088(d)
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85088 Fixtures, Furniture, Equipment and Supplies (d) If the facility operates its own laundry, necessary supplies shall be available and equipment shall be maintained in good repair.
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Administrator to provide training to all staff and generate a check off list of daily duties. Training materials and sign in sheet will be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA observation of dryer not functioning during visit. Per Administrator it was not functioning for a "couple of weeks" This poses a potential health, safety and/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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20220725085334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MEDINA RES. CARE SVCS., LTD LLC RAMONA RESIDENCE
FACILITY NUMBER: 107206669
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2023
Section Cited
CCR
80072(2)
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80072 Personal Rights (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Administrator to provide training to all staff and generate a check off list daily duties. Training materials and sign in sheet will be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA observation of faciilty staff smoking outside of facility and facility had a lindering odor of smoke upon entry into the facility. This poses a potential health, safety and/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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4