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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208918
Report Date: 08/04/2023
Date Signed: 08/04/2023 06:53:45 PM


Document Has Been Signed on 08/04/2023 06:53 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:HARVEST AT FOWLER, THEFACILITY NUMBER:
107208918
ADMINISTRATOR:ZANIN, ALEXFACILITY TYPE:
740
ADDRESS:1400 E SUMNER AVETELEPHONE:
(559) 834-5692
CITY:FOWLERSTATE: CAZIP CODE:
93625
CAPACITY:36CENSUS: 28DATE:
08/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:43 PM
MET WITH:Administrator, Alex ZaninTIME COMPLETED:
07:12 PM
NARRATIVE
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On 8/4/23 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced case management visit. LPA met with Administrator, Alex, introduced self, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in common areas and in private rooms.

Case management is being completed on an incident that occurred 1/27/23 where R1 jumped a fence and AWOL'd from the facility. Physicians report dated 12/20/23 stated that R1 was "able to leave the facility unassisted". CCL received a Special Incident report stating that on 3/9/23 R1, jumped the fence and AWOL'd from the facility resulting in injury and requiring medical attention. Physicians Report dated 2/17/23 stated that R1 was "not able to leave the facility unassisted".

This posed an immediate health, safety and or personal rights risk to resident in care. Deficiency cited per Title 22 for the absence of care and supervision on the attached LIC 809D. Immediate civil penalty assessed.

Exit interview completed with Administrator, Alex. A copy of this report, appeal rights and civil penalty provided.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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 08/04/2023 06:53 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: HARVEST AT FOWLER, THE
FACILITY NUMBER: 107208918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2023
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
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Administrator to provide email to CCL by POC describing actions to be taken by facility. Administrator to provide in-service training to all staff. Training material and in-service training sheet to be provided to CCL by 8/14/23.
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This requirement was not met as evidence by: LPA observation of Incident report. On 3/9/23 R1, jumped fence and AWOL'd from the facility resulting in an injury requiring medical attention.602 dated 2/17/23 stated that R1 was "not able to leave the facility unassisted". This posed an immediate health, safety and or personal rights risk to resident in care. Civil penalty assessed.
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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: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
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