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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206784
Report Date: 02/03/2025
Date Signed: 02/03/2025 05:33:42 PM

Document Has Been Signed on 02/03/2025 05:33 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:CHARLOTTE'S PLACE, INC.FACILITY NUMBER:
107206784
ADMINISTRATOR/
DIRECTOR:		GRAY, CHARLOTTEFACILITY TYPE:
735
ADDRESS:4262 N. GLENN AVETELEPHONE:
(559) 478-4403
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 4DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Licensee/Administrator, Charlotte Gray and House Manager, Maria GalindoTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 02/3/2025, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Licensee/Administrator, Charlotte Gray via telephone. Administrator and House Manager, Maria Galindo arrived a short while later.

During the inspection the facility appeared odor free and at a comfortable temperature. Common areas were furnished and had adequate seating and lighting available. Resident bedrooms had required furnishings. LPA observed dust on fans & cobwebs on walls/ Blinds. Debris under furniture and in closets. Light switch cover broken in bedroom. Missing Bulbs in the Ceiling Fan. Residents’ bathrooms appeared clean, water temperature measured at 111.6 degrees F. Facility kitchen appeared to be clean and safe for food preparation. Food supply checked.

Exterior tour conducted, all exits open and free of obstructions on today’s visit. LPA observed Backyard gate did not open all the way. Covered patio observed with seating. Fire extinguisher is current with a service date of 4/10/2024. Smoke detectors observed to operational. Carbon monoxide detector was inoperable even after battery was replaced. Last fire drill conducted in August 2024. Cleaning supplies observed to be locked in a cabinet. LPA reviewed Resident and staff files. Resident (R1) did not have admission agreement on file, Resident (R2) did not have a current medical assessment. Facility has a fire clearance for 6 non-ambulatory residents however LPA observed Resident (R3) has a bedridden status on medical assessment. LPA reviewed resident P & I ledger and was unable verify resident funds due to missing bank statement records. Medications observed to be locked and administered as prescribed.

CONTINUED TO 809C.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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 10
Document Has Been Signed on 02/03/2025 05:33 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/03/2025 at 04:26 PM
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: CHARLOTTE'S PLACE, INC.
FACILITY NUMBER: 107206784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of one carbon monoxide detector was inoperable which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Licensee agrees to purchase a new Carbon Monoxide and submit proof to CCLD by due date.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one out of one Resident (R3) is Bedridden; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Licensee agrees to submit an application for a new fire clearance to CCLD by due date.
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: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 02/03/2025 05:33 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/03/2025 at 04:26 PM
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: CHARLOTTE'S PLACE, INC.
FACILITY NUMBER: 107206784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one out of one resident (R2) who is over the age of 60 with a medical assessment from 2015 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Licensee agrees to schedule Doctors appointment by due date and submit copies of medical assessment once completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 02/03/2025 05:33 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/03/2025 at 04:26 PM
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: CHARLOTTE'S PLACE, INC.
FACILITY NUMBER: 107206784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 4 areas, LPA observed dust on fans & cobwebs on walls/ Blinds. Debris under furniture and in closets. Light switch cover broken in bedroom. Backyard gate did not open all the way. Missing Bulbs in the Ceiling Fan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee agrees to conduct a deep cleaning and replace any damaged items and submit pictures by due date.
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 4 out of 4 resident's current P& I funds could not be verfied which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee agrees to submit copies of the ledger and copies of the resident funds.
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: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 02/03/2025 05:33 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/03/2025 at 04:26 PM
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: CHARLOTTE'S PLACE, INC.
FACILITY NUMBER: 107206784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 4 resident (R1) is mising a Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee agrees to locate or obtain a copy of the admission agreement and submit to CCLD by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
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: CHARLOTTE'S PLACE, INC.
FACILITY NUMBER: 107206784
VISIT DATE: 02/03/2025
NARRATIVE
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LPA is requesting the following documents be submitted to the Fresno CCL office by 02/10/2025: 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 (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020) Surety Bond, Infection Control Plan.

Deficiencies are being issued on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. An immediate civil penalty is being assessed for $250 due to repeat violations.

Exit interview conducted and a plan of correction was reviewed and developed with House Manager. A copy of this report and appeal rights were discussed and provided House Manager, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
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