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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208900
Report Date: 05/16/2024
Date Signed: 05/16/2024 11:47:31 AM


Document Has Been Signed on 05/16/2024 11:47 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:CALIMYRNA ASSISTED LIVINGFACILITY NUMBER:
107208900
ADMINISTRATOR:PETERS, TYSONFACILITY TYPE:
740
ADDRESS:1545 W CALIMYRNA AVETELEPHONE:
(559) 412-2335
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
05/16/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Licensee, Tyson PetersTIME COMPLETED:
11:48 AM
NARRATIVE
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On 5/16/24 Regional Office Manager, B. White, Licensing Program Manager, S. Moua and Licensing Program Analyst M. Garza had an in office meeting held for an initial complaint visit (#24-AS-20240509105631). Licensee, Tyson Peters, Licensee, Robert McKnight and Administrator, Carlo Santos were present in office. Licensees, Kurt Zumwalt was unavailable for this meeting.

During visit interviews were completed with Licensees and Administrator.

At this time the complaint NEEDS FURTHER INVESTIGATION.

During the course of the investigation it was found that S1 was not fingerprint cleared and associated. It was also found that the incident on 3/20/24 was not reported as required by completing an SOC 341 to CCL and Ombudsman.

Deficiencies cited per Title 22. Civil penalty assessed for S1 not being fingerprint cleared.

Exit interview completed with Licensee, Tyson Peters and Administrator, Carlo Santos. A copy of this report, deficiencies, civil penalty and appeal rights was provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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 05/16/2024 11:47 AM - 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: CALIMYRNA ASSISTED LIVING
FACILITY NUMBER: 107208900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2024
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance - Obtain a California clearance or a criminal record exemption as required by the Department. Staff Monique Enez Conigliaro is not fingerprint cleared. Immediate civil penalty of $500.00 will be assessed.
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Licensee has removed S1 from employment and stated that S1 will not return until fingerprint cleared and associated.
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This requirement was not met as evidence by: LPA interviews and records reviewed it was confirmed that S1 was not fingerprint cleared or associated to the facility and was working there at the time of the incident. This poses an immediate health, safety and or personal rights risk to residents in care.
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Type A
05/17/2024
Section Cited
CCR87405(d)(2)

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Administrator - Qualifications and Duties - Knowledge of and ability to conform to the applicable laws, rules and regulations. Staff Carlo Santos, who the facility refers to as the Administrator did not ensure staff was fingerprinted and cleared to work in the facility.
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Licensee stated the Administrator qualification will be reviewed. Statement for completion of the training will be sent to CCL by POC date.
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This requirement was not met as evidence by: LPA's review of documentation. The facility failed to assure S1 was fingerprint cleared or associated to the facility and failed to report per reporting requirements (SOC 341). This poses an immediate health, safety and or personal rights risks 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: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2