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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107207121
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:00:45 PM


Document Has Been Signed on 10/03/2024 03:00 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:NINA'S HOMEFACILITY NUMBER:
107207121
ADMINISTRATOR:RODRIGUEZ, LETICIAFACILITY TYPE:
740
ADDRESS:6540 N. BRIARWOODTELEPHONE:
(559) 253-3024
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 4DATE:
10/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Administrator, Leticia RodriguezTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/03/2024 Licensing Program Analyst (LPA) M. Garza arrived at the facility completed an unannounced visit to deliver complaint findings. LPA met with Direct Care Staff, Otilio Barragan, stated reason for visit and was permitted entry into the facility. Administrator, Leticia Rodriguez was contacted and arrived some time later.

LPA completed a health and safety check on residents in care. Residents observed in dining area having lunch.

During this visit it was observed that Staff #1 (S1), Otilio Barragan was present and working at the facility. Facility does not have personnel file on S1 and they were working without a Criminal Background Clearance or facility association. Per Administrator, S1's first day at the facility was 10/02/24.

Based on today’s visit, deficiencies are being cited in accordance with Title 22 on the attached LIC 809D for the dates of 10/02/2024 through 10/03/24. An immediate civil penalty in the amount of $200 is being assessed for fire clearance.


An exit interview completed with Administrator, Leticia. A copy of this report, deficiencies and Appeal Rights were given to Administrator, Leticia.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
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 10/03/2024 03:00 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: NINA'S HOME
FACILITY NUMBER: 107207121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2024
Section Cited
CCR
87355(e)(b)(1)

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87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record
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Staff was immediately removed from the facility and not to return to work until fingerprint/background clearance completed. Licensee stated they are going to provide a POC in writing to CCL by POC date.
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This requirement was not met as evidence by: LPA observation of S1 working at facility and Licensee not ensuring all staff present at the facility have received criminal record clearance and been associated to the facility. This poses an immediate 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.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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