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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208918
Report Date: 05/21/2024
Date Signed: 05/23/2024 08:42:47 AM


Document Has Been Signed on 05/23/2024 08:42 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: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: 27DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Administrator, Alex ZaninTIME COMPLETED:
05:01 PM
NARRATIVE
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On 5/21/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Administrator, Alex Zanin. LPA 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 toured the facility inside and out. Residents observed in common areas and in rooms. There were 8 residents on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operate on a system. Fire extinguisher last serviced 2/1/24. Last fire drill was on 3/29/24. Water temperature measured in sample bathrooms. Temperature measured from 106.3 to 114.8 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps and medications were located in locked closets/rooms. LPA observed sufficient seating under covered patio areas. Sample file review completed for staff and residents.

The following issues were observed during visit: Water damage stain to ceiling in room #106 in need of paint. Doors blocking exit in right side hallway. Chemicals observed in various resident bathrooms. Bar soaps observed in bathrooms. Chemicals and objects that could poses a danger to residents in activity room. Food in kitchen freezers improperly labeled/stored. room #305 observed with oxygen tank without sign posted. Hospital bed for hospice resident with railing in room #308. Facility does not have hospice care plan for hospice resident. Garden bench broken and missing seat.

CONT...
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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 4


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
VISIT DATE: 05/21/2024
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CONT...


LPA requested the following documents to be submitted to CCL by 5/31/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Deficiencies cited on 809D per Title 22. Exit interview completed with Administrator, Alex Zanin. A copy of this report, deficiencies, TV's and appeal rights were given.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/23/2024 08:42 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: HARVEST AT FOWLER, THE
FACILITY NUMBER: 107208918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above in that various resident bathrooms and activity cabinet was observed with chemical/items that could pose a danger to residents in care unlocked and accessible. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator stated they will place all residents belongings (chemical/hygeine products) in locked rooms until cabinets can have locks added. Receipts/pictures to be sent to CCL by POC date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above in that room #305 was observed with an oxygen tank inside without "oxygen in use signs posted as required. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Posting was immediately posted outside the room. Training to be completed with all staff. In service sign in sheet and training material to be provided to CCL by POC date.
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: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/23/2024 08:42 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: HARVEST AT FOWLER, THE
FACILITY NUMBER: 107208918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interview with Administrator, the licensee did not comply with the section cited above in that R1 was admitted on hospice 5/18/24. A hospice care plan/training was not secured by the facility at time of admittance. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator to contact Hospice agency to get Care Plan. A copy of the care plan will be sent to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4