107208813-8-31-2023-24-AS-VGON-CV8SU8-20230831141040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208813
Report Date: 08/31/2023
Date Signed: 08/31/2023 02:11:39 PM

Document Has Been Signed on 08/31/2023 02:11 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:	MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEA		FACILITY NUMBER:	107208813
ADMINISTRATOR:	MAREZ, PHOEUN		FACILITY TYPE:	740
ADDRESS:	292 W TRENTON AVE		TELEPHONE:	(559) 298-7992
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93619
CAPACITY:	6	CENSUS: 6	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Assistant Administrator, Jordan Brice		TIME COMPLETED:	01:30 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 08/31/2023, Licensing Program Analyst (LPA) V. Gorban 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. LPA toured facility with Administrator assistant (AA) Jordan Brice was notified of Licensing visit over the phone and was able to attend the visit. AD, Nastassha Brice, license certification number 6044412740 and expiration date 5/01/25 was also notified of Licensing visit. Facility has one entrance/exit point. LPA toured facility with Administrator inside and out. Facility pool serviced weekly. LPA observed pool in the back yard fenced and the gate to the pool was locked for safety of residents. The facility was observed to be at a comfortable temperature, of 75 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed some residents in common area after breakfast, others in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility. Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. Fire extinguisher was observed with a service date of 08/31/2023. All 6 residents’ bedrooms were observed to be with comfortable temperature. Bathroom water temperature was tested and recorded reading of 107 degrees F. Report continues on LIC809-C

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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 2

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: MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEA	FACILITY NUMBER: 107208813
	VISIT DATE: 08/31/2023

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

Medications observed to be locked in a cabinet in the kitchen. LPA reviewed medication records, it appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the laundry room. An outdoor seating area was observed for residents in care.

LPA reviewed Staff and Resident files. Resident files observed to have updated information.

LPA requested following documents to be provided to CCL office by 9/07/23:

LIC 308 Designation of Facility Responsibility
LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Administrator Certificate

No deficiencies were observed and cited. Exit interview conducted. Report was signed and copy of this report was provided for facility records.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2