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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209035
Report Date: 07/12/2024
Date Signed: 07/12/2024 03:56:27 PM


Document Has Been Signed on 07/12/2024 03:56 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:TRUEWOOD BY MERRILL, CLOVISFACILITY NUMBER:
107209035
ADMINISTRATOR:MAZON, PAMELAFACILITY TYPE:
740
ADDRESS:675 W ALLUVIAL AVENUETELEPHONE:
(559) 325-8400
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:148CENSUS: 90DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator Pamela MazonTIME COMPLETED:
04:15 PM
NARRATIVE
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On 07/12/24, Licensing Program Analysts (LPA) M. Yang and J. Leffall arrived at the facility unannounced to conduct the Annual Inspection. LPAs met and toured facility with Administrator Pamela Mazon.

Facility has sufficient furnishings inside and outside for resident use. The facility was observed to be at a comfortable temperature, clean, and no passageway obstructions or fire hazards. LPA toured a sample of resident bedrooms in Assisted Living and Memory Care. LPA toured facility library, activity room, and moving room. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lightning. Residents were observed seating in common areas and dining areas. Facility is equipped with pull stations and fire sprinklers throughout facility. Fire extinguisher was observed throughout the facility with a service date of: 11/17/23. LPAs toured kitchen. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Temperature for refrigerator observed maintained at 37 degrees F and freezer maintained at 0 degrees F.

LPAs observed washer and dryer operational in laundry room. LPAs observed medications, chemicals, and tools unlock in resident’s room. Bathrooms hot water temperature was tested and within range between 116.2 to 111.5 degrees F. LPAs observed securely fastened grab bars and non-skid surfaces in shower. Outside was toured and observed adequate outdoor seatings available for residents. A sample of resident and staff files were reviewed to have all the required documents. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title
22, Division 6. Exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 07/18/24. LPAs received a copy of Lic 500. The following updated forms were requested: Lic 308, Lic 309, Lic 610E, current liability insurance, and Administrator Certificate. A copy of this report and appeal rights was provided to Administrator, whose signature confirm receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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 07/12/2024 03:56 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: TRUEWOOD BY MERRILL, CLOVIS
FACILITY NUMBER: 107209035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on interviews, records review, and observation, MARs were reviewed, and medications were audit and shown that staff did not administer medications for memory care resident R1 and R2 as directed by physician, which poses an immediate health and safety risk for the person in care.
POC Due Date: 07/13/2024
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation on administering medications as directed by physician to Fresno CCL office by POC due date 07/12/24.

Licensee shall have all memory care staff be retrained to meet regulations. Licensee will submit documentation of training topics which include process of administering medications with staff attendance rooster to the Fresno CCL office by 07/25/24.
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...

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 LPAs and A1 observed medications in kitchen shelf in room 144 unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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Administrator immediately removed medications to locked medication room. POC cleared during visit.
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: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/12/2024 03:56 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: TRUEWOOD BY MERRILL, CLOVIS
FACILITY NUMBER: 107209035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Disinfectants, cleaning solutions, poisons, firearms 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 observation, the licensee did not comply with the section cited above when LPAs and Administrator observed in room 144 tools unlock in kitchen drawer. Knives were observed room 225 kitchen drawer unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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Administrator immediately removed tools and knives during inspection. 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: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3