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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208943
Report Date: 06/09/2023
Date Signed: 06/09/2023 02:22:43 PM


Document Has Been Signed on 06/09/2023 02:22 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:DIGNITY GARDENS HOME IIFACILITY NUMBER:
107208943
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:2814 RIALTO AVETELEPHONE:
(559) 515-6189
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Caregiver Donte Gaynor and Licensee/Administrator Camalah Kopacz TIME COMPLETED:
02:00 PM
NARRATIVE
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On 6/9/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection visit. LPA introduced self, stated the purpose of the visit, and was greeted by caregiver Donte Gaynor. LPA was granted entry into the facility. Licensee/ Administrator Camalah Kopacz was called and stated unable to attend meeting. LPA toured facility with designee. All five resident were present upon LPA arrival. LPA conducted interviews with staff and resident.

The tour started in the kitchen into the common areas, to the resident's bedrooms, and bathrooms. LPA
observed COVID-19 related signs. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Medications are kept locked in kitchen cabinet. MARs was review. An adequate supply of perishable and non-perishable food was observed. At approximately 11:30 AM, medication boxes were stored unlock in refrigerator unlock. Fire extinguisher was observed with a service date of: 06/02/23. Cleaning supplies and chemicals stored and locked in laundry room. LPA toured all resident’s bedrooms and observed 4 single occupant rooms. Residents’ room observed to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms were properly equipped, and the hot water temperature was tested at 112.4 degrees F in bathroom 1 and range 111.4 to 111.6 degrees F in master bathroom. The exterior tour was conducted. Side gate was self-closing and self-latching. All residents’ file reviewed to have update emergency contacts and Admission agreement and Pre-Appraisal. Sample of staff's files were also reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility. Carbon monoxide and smoke detectors were tested and observed to be operational.
A deficiency is being cited on the attached Lic 809D. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 6/15/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, current liability insurance, transportation procedure, theft and loss policy/procedure, and current Administrator certificate. A copy of this report and appeal rights was provided to Licensee/Administrator.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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 06/09/2023 02:22 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: DIGNITY GARDENS HOME II
FACILITY NUMBER: 107208943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental Care Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed at approximately
11:30 AM, three residents’ medication boxes were stored unlock in refrigerator accessible to residents which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 06/10/2023
Plan of Correction
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Staff immediately locked medications in medication lock box in refrigerator. POC cleared during visit.
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) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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