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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208895
Report Date: 03/21/2023
Date Signed: 03/31/2023 09:58:38 AM

Document Has Been Signed on 03/31/2023 09:58 AM - 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:SIERRA MEADOWS BEHAVIORAL HEALTHFACILITY NUMBER:
107208895
ADMINISTRATOR:TATUM, MATTHEWFACILITY TYPE:
772
ADDRESS:2343 DEAUVILLE CIRCLETELEPHONE:
(559) 593-9801
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 5DATE:
03/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Program Director, Amanda FrantzTIME COMPLETED:
03:15 PM
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On 3/31/2023, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit.
LPA introduced self and was allowed entrance by staff. LPA met with Program Director Amanda Frantz

LPA amended report issued on 3/21/23.
LPA arrived at the facility to conduct case management visit for incident report CCLD received with date incident occurred on 3/13/2023 regarding C1 was given a full dose pill of .50 mg instead of .25mg the current taper order.
Side effects are as noted on the medication bottle drowsiness, dizziness.

LPA interviewed Administrator and med personnel. Initial order of Klonopin was prescribed on 3/14/23 one pill once a day. On 3/15/ 23 order was altered, instead of .50 mg once a day, order medication was dispensed .25 mg twice per day per client’s request.
Client was monitored for any possible side effects such as dizziness and nausea.
LPA attempted to interview client. C1 was discharged form facility on 3/16/23 due to step down in assessment.
Facility staff enhance educational training program for med techs on how to handle medications properly, more efficiently, with less errors, and follow proper dose disposal. Completed training will be provided to department once class completed.

An exit interview was conducted with Administrator. Amended report signed on-site and a copy of report was provided.

Original report was returned to LPA.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 03/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/31/2023
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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