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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208997
Report Date: 12/10/2024
Date Signed: 12/10/2024 05:08:56 PM

Document Has Been Signed on 12/10/2024 05:08 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:SVS KINGSBURGFACILITY NUMBER:
107208997
ADMINISTRATOR/
DIRECTOR:		REYNOSO, DAWNFACILITY TYPE:
775
ADDRESS:1654 CALIFORNIA STREETTELEPHONE:
(559) 443-7119
CITY:KINGSBURGSTATE: CAZIP CODE:
93631
CAPACITY: 60CENSUS: 35DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:37 AM
MET WITH:Regional Director, Dawn ReynosoTIME VISIT/
INSPECTION COMPLETED:
05:16 PM
NARRATIVE
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On 12/10/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Case Manager, Maria Betancourt introduced self, explained reason for visit and was permitted entry into the facility. Regional Director, Dawn Reynoso was contacted and arrived some time later.

LPA completed a health and safety check on clients in care. LPA toured the facility. Clients observed in activity rooms. The facility currently has 5 non-ambulatory clients in care. 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 operate on a system and were last serviced on 7/9/2024. Fire extinguisher last serviced 07/09/2024. Last fire drill on 10/17/2024. Water temperature measured 115.5 degrees F in activity room and 110.8 degrees F in the kitchen. Activity rooms observed to have the required furnishings and with adequate lighting. LPA observed seating under covered patio areas.

The following issues were observed during todays visit: Chemicals observed in Activity Room #1 unlocked and accessible. Chemicals observed in Activity Room #4 unlocked and accessible. Sharp observed in Activity Room in cabinet unlocked and accessible. Sharp observed in kitchen unlocked and accessible. Food in kitchen improperly stored/dated. Food improperly stored in staff freezer/cabinet.

LPA requested the following documents to be submitted to CCL by 12/20/24: Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Deficiencies cited per Title 22. Exit interview completed with Regional Director, Dawn and Case Manager, Maria. A copy of this report, deficiencies, TV's and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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 12/10/2024 05:08 PM - It Cannot Be Edited


Created By: Mary Garza On 12/10/2024 at 04:43 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: SVS KINGSBURG
FACILITY NUMBER: 107208997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, 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 bservation, the licensee did not comply with the section cited above in that chemicals observed in Activity Room #1 unlocked and accessible. Chemicals observed in Activity Room #4 unlocked and accessible. Sharp observed in Activity Room in cabinet unlocked and accessible. Sharp observed in kitchen unlocked and accessible.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Facility staff will conduct a walk through to collect all chemicals/items posing a danger to clients in care and ensure they are locked and locked and inaccessible. Training will be compelted with all staff. In-service sign in sheet and training material will be provided to CCL by POC date.
Type B
Section Cited
HSC
1565.5(d)
Other Provisions
In addition to any other requirement of this chapter, an adult day program, as defined in Section 1502, shall have an emergency and disaster plan that includes, but is not limited to, all of the following: (d) The location of all utility shut-off valves and instructions for use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that Emergency Disaster Plan does not have locations of shut off or instructions listed. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Facility will update Emergency Disaster Plan. Regional Director stated training will be completed with all staff on the plan. An in-service sign in sheet and training material will be submitted 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 Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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