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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208930
Report Date: 04/02/2024
Date Signed: 04/02/2024 05:05:19 PM


Document Has Been Signed on 04/02/2024 05:05 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:WINDHAM, THEFACILITY NUMBER:
107208930
ADMINISTRATOR:EARLEY, JOHNFACILITY TYPE:
740
ADDRESS:1100 E SPRUCE AVETELEPHONE:
(559) 449-8070
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:88CENSUS: 79DATE:
04/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator, John EarleyTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) V Gorban conducted a Case Management visit. During this visit LPA met with facility the facility clerk Charles Flood and explained the purpose of the visit. Administrator (AD) John Earley was notified of Licensing visit and was able to attend it.

Case Management visit was conducted based on the incident report occurred on 3/20/24 with R1. During this visit LPA conducted health and safety facility check and observed and interviewed R1 and R2. Based on facility records R1 received morning medications prepared for R2, which poses health and safety risk to residents in care.

Cited violation attached on LIC809-D.

Exit interview conducted, report signed and copy of this report with appeal rights provided to AD for facility records.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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 04/02/2024 05:05 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: WINDHAM, THE
FACILITY NUMBER: 107208930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/03/2024
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care
(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This was not observed as evidenced by
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FAcility Administrator will retrained med techs on how to administer medications to residents/ couple to avoid future errors. AD will provide staff training receipts on medication dispensing to LPA by email by 4/03/24
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Facility failed to administer medications as prescribed. R1 was provided medications prescribed for R2. This poses an immediate health and safety 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: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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