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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208918
Report Date: 04/28/2025
Date Signed: 04/28/2025 05:33:11 PM

Document Has Been Signed on 04/28/2025 05:33 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/
DIRECTOR:		ZANIN, ALEXFACILITY TYPE:
740
ADDRESS:1400 E SUMNER AVETELEPHONE:
(559) 834-5692
CITY:FOWLERSTATE: CAZIP CODE:
93625
CAPACITY: 36CENSUS: DATE:
04/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Administrator, Alex ZaninTIME VISIT/
INSPECTION COMPLETED:
05:34 PM
NARRATIVE
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On 4/28/2025 Licensing Program Analyst (LPA) M. Garza completed an case management visit. LPA met with Administrator, Alex Zanin, explained reason for visit and was permitted entry into the facility. LPA toured facility and completed a health and safety check on residents in care. Residents were observed in common areas and in rooms.

This case management visit is being conducted for incident reports that were received by the Department that required additional information. LPA requested and reviewed residents files (physicians reports, needs and services plans, reappraisals, hospital discharge paperwork, special incident reports (SIR) and logging notes) for R1, R2, R3, R4 and R5.

Incident 1:The Department received an SIR for an incident that occurred on 1/8/25 for R1. During a shower R1 fell out of the shower chair and was complaining of right should pain. R1 was sent to the hospital and upon discharge was sent to Skilled Nursing Facility with a broken clavicle. Per SIR, R1 had UTI and possible pneumonia. File review of charting notes did not disclose any previous indications of change in condition. No deficiency cited for this incident.

Incident 2: The Department received an SIR for R2 for an incident that occurred on 2/21/25. Staff completed a 6am check on R2 and found them not feeling well. EMS was contacted and R2 was transferred to the hospital. Resident was treated for the flu. File review of charting notes disclosed on 2/14/25 R2 had a fall. On 2/13/25 it is noted R2 is "a bit off". On 2/15/25 it is noted R2 "not felling well". From 2/3/25-2/21/25 there were other residents ill. No SIR's received for illnesses by the Department. Deficiency cited per Title 22.

CONT...
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/28/2025
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CONT...

Incident 3: The Department received an SIR for an incident that occurred on 3/6/25 for R3. R3 had a fall bumping their head on the dresser. R3 obtained a 2 cm laceration to the right side of their head. EMS was contacted and transported R3 to the hospital. File review completed. Physicians report dated 12/18/24 states R3 requires assistance with all ADL's and requires some supervision. Review of hospital discharge stated R3 has small abrasion on scalp and can walk with assist and walker. Deficiency cited per Title 22.

Incident 4: The Department received an SIR for an incident that occurred on 4/10/2025. R4 had an un-witnessed fall hitting the back of their head and complaining of left shoulder pain. EMS was called and R4 was transported to the hospital. Resident file reviewed. Functional Capability Assessment (not dated). Physicians report dated 3/10/25 states R4 has motor impairment/paralysis with no diagnosis listed. R4 is on 2 hour checks, will sometimes assist with transferring and to the restroom. No deficiency cited.

Incident 5: The Department received an SIR for an incident that occurred on 4/16/25. During a shower R5 became pail, unresponsive, drooling and shaking. EMS was contacted and transported R5 to the hospital. Discharge paperwork stated dx of syncope and a follow up with PCP in 1 week. Follow up with neurologist is scheduled for 4/29/25 and an additional appointment with the cardiologist on 8/14/25. No deficiency cited.

Exit interview completed with Administrator, Alex. A copy of this report, deficiencies and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2025 05:33 PM - It Cannot Be Edited


Created By: Mary Garza On 04/28/2025 at 02:23 PM
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: HARVEST AT FOWLER, THE
FACILITY NUMBER: 107208918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87466

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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Administator stated they feel everything was completed by them with the expception of lack of documentation. Administrator stated they will generate a contact form to log attempts with family in getting timely medical attention for residents. Administrator stated they will provide a copy of this form to CCL by POC date as proof of correction.
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This requirement was not met as evidence by: file review. The licensee did not comply with the section cited above in that it was noted in the staff log book R2 was observed to be ill on 2/13/25 and was not taken to the physician. R2 was sent out via EMS to the hospital on 2/21/25. R2 did not receive timely medical attention for their illness. This poses a potential health safety and or personal rights risk to persons 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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2025


LIC809 (FAS) - (06/04)
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