107208764-8-8-2023-24-AS-KKAR-CUHRGQ-20230808130106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208764
Report Date: 08/08/2023
Date Signed: 08/08/2023 01:01:15 PM

Document Has Been Signed on 08/08/2023 01:01 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:	WILLIAM'S RESIDENTIAL CARE FOR THE ELDERLY LLC		FACILITY NUMBER:	107208764
ADMINISTRATOR:	RUNDERSON, MARTHA M		FACILITY TYPE:	740
ADDRESS:	2909 EAST GRIFFITH WAY		TELEPHONE:	(559) 226-1082
CITY:	FRESNO	STATE: CA	ZIP CODE:	93726
CAPACITY:	3	CENSUS:	DATE:	08/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:			TIME COMPLETED:	01:15 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 8/8/2023, 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 Administrator Martha Runderson. The facility was observed to be at a comfortable temperature, clean, in good repair, no passageway obstructions were observed inside or outside. Common areas were properly furnished and well-lit throughout. Facility has 3 residents who are at day program at time of inspection. The dining room is equipped with a table and chairs, living room is equipped with adequate sofas and recliners for 3 residents, adequate outside space for rest and recreational. Backyard gate is self-closing and self-latching. At 11:29 AM LPA did not observe 7-day supply of non-perishable foods. 2-day supply of perishable foods observed. Fire extinguisher in Kitchen was last serviced on 8/1/2023 and was fully charged. Knives are locked in the hallway closet with the medication. Cleaning and Chemical supplies are kept in locked in the locked laundry area in the hallway. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available in residents’ rooms. Carbon monoxide and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid mats in place. LPA reviewed Resident's records contained signed Admission Agreement, Personal Rights, current Physician’s Report, emergency contact, and Needs & Services plans. Staff files were reviewed for good health, First Aid training, at least one staff on duty who is CPR certified. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. Continued on LIC809-C...

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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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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: WILLIAM'S RESIDENTIAL CARE FOR THE ELDERLY LLC	FACILITY NUMBER: 107208764
	VISIT DATE: 08/08/2023

NARRATIVE

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LPA is requesting the following documents be submitted to the Fresno CCL office by 8/15/2023: 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.

An exit interview was conducted with Administrator. Deficiencies and corrections reviewed with Administrator. Report signed on-site; printed copy provided including appeal rights.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2023 01:01 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: WILLIAM'S RESIDENTIAL CARE FOR THE ELDERLY LLC	FACILITY NUMBER: 107208764
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1, 7-day supply of non-perishable foods was not observed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	Administrator to restock non-perishable food and submit pictures and receipts as proof of correction by due date.

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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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