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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206790
Report Date: 01/08/2024
Date Signed: 01/08/2024 01:00:32 PM


Document Has Been Signed on 01/08/2024 01:00 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:ALEXANDER ADULT RESIDENTIAL CAREFACILITY NUMBER:
107206790
ADMINISTRATOR:ALEXANDER, NICOLEFACILITY TYPE:
735
ADDRESS:381 S 3RD STREETTELEPHONE:
(559) 842-3090
CITY:KERMANSTATE: CAZIP CODE:
93630
CAPACITY:6CENSUS: 4DATE:
01/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nicole Alexander, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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On 01/08/24 Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual
Inspection. LPA introduced self, stated the purpose of the visit, and was greet by Administrator Nicole Alexander. LPA was granted entry. All four clients were present upon LPA arrival. One client left to day program during inspection.

LPA toured facility. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -1 degrees F and refrigerator temperature was maintained at 36 degrees F. Fire extinguisher was observed with a service date of: 10/10/23. Fire drill last completed on 10/06/23.



Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operating. Hot water temperature was tested 116.2 degrees F. in bathroom 1 and 113.3 degrees F. in bathroom 2. Cleaning chemicals was observed stored and locked in the laundry cabinet. Outside of facility toured. Side gate was self-closing. Outside was observed with adequate outdoor seatings available for clients.

All clients’ file reviewed to have all the required documents. Staff files were reviewed and observed to have all the required documents. Medications were checked and observed kept locked in hall closet. Clients’ MARS was reviewed. Carbon monoxide and smoke detectors were tested and observed to be operational.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6. Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 01/15/24: Lic 308, Lic 309, Lic 500, Lic 610D, Lic 9282, and Lic 9020. LPA received a copy of current Administrator certificate. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of these report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
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 01/08/2024 01:00 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: ALEXANDER ADULT RESIDENTIAL CARE
FACILITY NUMBER: 107206790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and observation, the licensee did not comply with the section cited above when LPA and Administrator reviewed C1’s medication and verified medication Risperdol .5mg was not administering at 7:00 PM on 01/07/24, which poses an immediate health and safety risks to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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Licensee shall submit a plan detailing steps the facility will take to ensure facility meets Health and Safety regulations for administering medications. Plan is to be submitted to the Fresno CCL office by due date 01/09/24.
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 MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
LIC809 (FAS) - (06/04)
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