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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208908
Report Date: 07/18/2023
Date Signed: 07/18/2023 02:32:36 PM


Document Has Been Signed on 07/18/2023 02:32 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:WESTMONT OF FRESNOFACILITY NUMBER:
107208908
ADMINISTRATOR:ERIK V. SCHUKFACILITY TYPE:
740
ADDRESS:7442 & 7468 N MILLBROOK AVETELEPHONE:
(559) 446-1266
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:155CENSUS: 112DATE:
07/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Erik SchukTIME COMPLETED:
09:30 AM
NARRATIVE
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On 7/18/23 Licensing Program Analyst, (LPA) V Gorban conducted a case management visit to the facility stated above regarding incident involved resident (R1) occurred in the facility reported on 6/14/2023, Incident was not reported until 6/26/23.

LPA stated purpose of the visit and met Administrator Erik Schuk. LPA toured facility with AD inside and out. LPA reviewed facility files and interview staff. LPA verified facility staff (S1) is currently not working in the facility. LPA interviewed AD and verified with AD that S1 has not been worked in facility since 6/16/23. Administrator provided disassociated S1 from facility personnel report provided by AD to LPA Gorban during visit.

Exit interview conducted, report signed, printed with appeal rights.

Deficiency cited on attached 809 D

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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Document Has Been Signed on 07/18/2023 02:32 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: WESTMONT OF FRESNO
FACILITY NUMBER: 107208908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2023
Section Cited
CCR
87211(a)(1)

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87211(a)(1) Reporting Requirements
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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For plan of correction (POC) Administrator agrees to review and submit a written statement on how this regulation will be met in the future by POC due date 7/30/23
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This requirement was not met as evidenced by LPAs record review. Licensee did not report incident of R1 which poses potential health and safety and/or personal rights risk 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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2