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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208895
Report Date: 12/29/2023
Date Signed: 12/29/2023 01:23:33 PM

Document Has Been Signed on 12/29/2023 01:23 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: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: 0DATE:
12/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Program Manager, Vanessa Samaniego.TIME COMPLETED:
10:33 AM
NARRATIVE
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On 12/29/23, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct a case management inspection to follow up on incident occurred on 12/21/23. LPA explained the reason for inspection and met with Program Manager, Vanessa Samaniego.

LPA toured the facility inside and out to conduct safety checks.

CCL received an incident report on 12/21/23 of potential HIPPA violation. C1's medical files were faxed to the incorrect destination number. The facility was notified of the incident by the party expecting the report but have not received it yet. Facility attempted to contact fax receiver on the same date of 12/21/23. C1 was notified on 12/28/23 of potential risk due to the records provided to unauthorized recipient.

Deficiency cited on LIC-809D

Exit interview conducted, report signed and copy of this report with appeal rights provided for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2023
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
Document Has Been Signed on 12/29/2023 01:23 PM - It Cannot Be Edited


Created By: Vadim Gorban On 12/29/2023 at 07:33 AM
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: SIERRA MEADOWS BEHAVIORAL HEALTH
FACILITY NUMBER: 107208895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
81070(c)

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81070(1) Client Records.
The licensee shall be responsible for safeguarding the confidentiality of record contents. This requirement was not met as evidenced by:
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Licensee and Administrator agrees on reiteration on HIPPA laws and staff training. providing by email to LPA by 01/05/24.
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Based on staff interview and records provided C1's personal medical file was sent by fax to incorrect destination which posses potential health and safety risk of 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:Brenda Chan
LICENSING EVALUATOR NAME:Vadim Gorban
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2023


LIC809 (FAS) - (06/04)
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