107206800-3-4-2025-24-AS-KKAR-DEFTK5-20250304134722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206800
Report Date: 03/04/2025
Date Signed: 03/04/2025 01:48:30 PM

Document Has Been Signed on 03/04/2025 01:48 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:	JAY HOMES INC SANGER		FACILITY NUMBER:	107206800
ADMINISTRATOR/ DIRECTOR:	RICHARDSON, MARY		FACILITY TYPE:	735
ADDRESS:	698 S DOCKERY		TELEPHONE:	(559) 286-6701
CITY:	SANGER	STATE: CA	ZIP CODE:	93657
CAPACITY: 6		CENSUS: 6	DATE:	03/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:01 AM
MET WITH:	Assistant Director of Operations Tanya Hicks		TIME VISIT/ INSPECTION COMPLETED:	02:15 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 3/04/2025, Licensing Program Analyst LPA K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff Lead Tamika Bonner and Assistant Administrator Damon Houwell. Staff contacted Licensee James Clark; a short while later Assistant Director of Operations Tanya Hicks arrived with staff files.

LPA conducted tour with Staff. Tour started in the facility kitchen. LPA observed sufficient food supply. The facility was observed to be at a comfortable temperature, in good repair, with no passageway obstructions or fire hazards. Fire extinguisher in the entry way was last serviced on 06/5/2024 and was fully charged. All common areas were properly furnished and well-lit throughout. Cleaning Supplies, Medications, First Aid, and Sharp items locked in the Storage Room. Smoke Alarm and Carbon Monoxide detector tested and operational. LPA toured 6 resident rooms, a game room and an office. Facility has three bathrooms. All client bedrooms toured and observed to be adequately furnished. Extra linens observed in the cabinet storage next to the laundry room. LPA toured laundry area which appeared clean. Cleaning supplies and chemicals observed locked in cabinet next to laundry. The exterior tour was conducted. The backyard was observed with a covered patio with sufficient seating for rest and recreational. Backyard gate opened with no difficulty and is self-latching.

Medication was reviewed. Staff records were reviewed for good health and training, all resident’s records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. All residents were missing functional capabilities assessment. Last fire drill completed on 2/3/2025.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

Continued to Next Page

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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 4

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: JAY HOMES INC SANGER	FACILITY NUMBER: 107206800
	VISIT DATE: 03/04/2025

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
26
27
28
29
30
31
32

LPA is requesting the following documents be submitted to the Fresno CCL office by 3/11/2025: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

Exit interview conducted with Assistant Director of Operations Tanya Hicks; a plan of correction was reviewed and developed. Report signed on-site; a copy of this report was emailed including appeal rights to Assistant Director, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 03/04/2025 01:48 PM - It Cannot Be Edited

Created By: Kamaldeep Kaur On 03/04/2025 at 01:36 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: JAY HOMES INC SANGER	FACILITY NUMBER: 107206800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.2(b)(1)(F)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 6 out of 6 residents were missing the written functional capabilities assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2025
	Plan of Correction
1 2 3 4	Licensee aggress to submit to CCLD by due date completed functional capabilities assessment forms and for new placement ensure documentation is completed at admission.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4