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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209086
Report Date: 12/28/2023
Date Signed: 12/28/2023 04:31:59 PM


Document Has Been Signed on 12/28/2023 04:31 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:BK HOUSE OF GRACE LLCFACILITY NUMBER:
107209086
ADMINISTRATOR:RIEMER, ROSEMARIE HFACILITY TYPE:
740
ADDRESS:1463 N ARCHIE AVENUETELEPHONE:
(559) 201-8329
CITY:FRESNOSTATE: CAZIP CODE:
93703
CAPACITY:6CENSUS: 6DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Rosemarie Reimer and Licensee, Balwinder KaurTIME COMPLETED:
04:45 PM
NARRATIVE
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On 12/28/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry by staff and requested to meet with the Administrator. Facility staff contacted Administrator, Rosemarie Reimer via telephone. Administrator and Licensee, Balwinder Kaur, arrived a short time later.

Facility tour conducted. LPA toured the facility kitchen. 7-day supply of non-perishable foods and a 2-day supply of perishable foods. At 9:10 AM LPA observed cleaning supplies to be accessible in a cabinet under the kitchen sink. Medications checked. Medication observed to be locked and inaccessible to residents in care in the closet. Fire extinguisher observed in kitchen which was last serviced on 01/18/2023. LPA toured outside and observed covered area for rest and recreational.

LPA observed a pile of clothing outside the staff bedroom. LPA inquired about the clothing and was informed the facility washer is non-operating. When staff try to use washer, it backs up the water in the bathrooms and toilet and leads to water overflowing. At 10:10 AM LPA continued tour to resident rooms and observed hallway lights to be non-operating. At 10:25 LPA observed bedroom fan and ceiling to have caked on dirt and debris. Debris observed throughout the facility flooring.

LPA reviewed Resident and staff files and observed missing admission agreement for one resident. Fire drill conducted on 12/18/2023. Due to time constraints, LPA will return at a later date for an annual continuation.

Continued to 809C
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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 12/28/2023 04:31 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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 in 1 out of 1 LPA observed debris on the floor throughout the facility and caked on dirt on bedroom walls and ceiling fan which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Licensee to have staff clean and maintain routine cleaning and provide pictures to CCLD by due date
Type A
Section Cited
CCR
87303(e)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 washer observed non-operating which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Licnesee to get washer repaired or provide replacement by due date and provide Receipt or invoice to CCLD by due 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 MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/28/2023 04:31 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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 residents file observed without admission agreement which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Licnesee to submit copy of signed admission agreement via email to CCLD by due date.
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) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086
VISIT DATE: 12/28/2023
NARRATIVE
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LPA is requesting the following documents be submitted to the Fresno CCL office by 01/04/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

Deficiencies are being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a Plan of Correction was reviewed and developed with Administrator and Licensee. A copy of this report was discussed and provided to Licensee, Balwinder Kaur, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/28/2023 04:31 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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(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 in 1 out of 1, LPA observed unlocked cleaning supplies to be accessible in a cabinet under the kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Licensee locked cabinet during inspection and will ensure staff lock cabinet while not in use.
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) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5