107208950-5-30-2023-24-AS-KKAR-CSBVCY-20230530161956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208950
Report Date: 05/30/2023
Date Signed: 05/30/2023 04:21:28 PM

Document Has Been Signed on 05/30/2023 04:21 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:	SERENITY GARDEN HOME 2		FACILITY NUMBER:	107208950
ADMINISTRATOR:	FLORES, GINA ONAG		FACILITY TYPE:	740
ADDRESS:	5409 E BUTLER AVE		TELEPHONE:	(559) 478-4504
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	6	CENSUS: 6	DATE:	05/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Administrator Phoeun Marez		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/30/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff Isagani Colocado. A tour of the facility was conducted with Administrator Phoeun Marez. Facility appeared cleaned with no obstruction or fire clearance issues. Fire extinguisher in kitchen was last serviced on 3/16/2023 and was fully charged. Hand sanitizer was readily available to residents and visitors. Bathrooms were properly equipped with non-slip mats and grab bars. LPA toured bedrooms with adequate furnishings and lighting. Adequate supply of linens observed in the hallway closet. Cleaning supplies and chemicals are kept locked in garage. LPA checked residents’ medications and observed a 2-week supply which is kept locked in cabinet in the kitchen. At 1:32 LPA reviewed resident’s medication against Centrally stored list and MARs and observed the pill count to be incorrect for one resident. Laundry area observed locked. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA observed sufficient seating under covered patio area in the back of the facility. At 2:10 PM LPA observed one resident Admission Agreement to be missing a resident/power of attorney signature. Resident's records contained Personal Rights, and current Physician's Report. Resident’s files have updated emergency contact information. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who is CPR certified. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. Continued on LIC809C...

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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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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: SERENITY GARDEN HOME 2	FACILITY NUMBER: 107208950
	VISIT DATE: 05/30/2023

NARRATIVE

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LPA is requesting the following documents be submitted to the Fresno CCL office by 6/28/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site and printed copy provided with appeal rights.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/30/2023 04:21 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: SERENITY GARDEN HOME 2	FACILITY NUMBER: 107208950
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 persons medication review which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Submit a correction plan for re-training of staff and estimated date of completion.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 05/30/2023 04:21 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: SERENITY GARDEN HOME 2	FACILITY NUMBER: 107208950
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review , the licensee did not comply with the section cited above in 1 out of 6 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	Administrator to have resident’s son sign the admission agreement and submit copy to CCLD by due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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