107209238-6-20-2023-24-AS-KKAR-CSYUAS-20230620152509

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209238
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:26:51 PM

Document Has Been Signed on 06/20/2023 03:26 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:	WESSON ARF, LLC		FACILITY NUMBER:	107209238
ADMINISTRATOR:	WESSON, BETTYE		FACILITY TYPE:	735
ADDRESS:	2274 S EDDY		TELEPHONE:	(310) 344-5116
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	4	CENSUS: 3	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Staff Hausan Wesson		TIME COMPLETED:	03:30 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 6/20/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA rang the doorbell and knocked on the door but did not receive a response. LPA contacted the Licensee via telephone and waited outside the facility until Licensee Bettye Wesson arrived. LPA was allowed entry into the facility by Licensee and was introduced to staff Hausan Wesson. One resident was at the facility during tour. LPA stated the purpose of the visit and started the tour with staff. All pathways, entrances and exits were clear from obstructions. LPA and staff began the tour at the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in kitchen was last serviced on 4/27/2023 and was fully charged. Tour continued to the living room which has sufficient seating. Tour continued to Residents Rooms. LPA toured three bedrooms which were observed to be furnished with required furniture and adequate lighting. At 12:33 LPA observed resident’s bedrooms to have debris on mattress and flooring. Linen supply is kept in the hallway closet. Cleaning supplies and chemicals are kept locked in the Master bedroom which is currently used as a staff bedroom. Medications are kept locked in the hallway closet. At 1:12 LPA observed the laundry room to have laundry detergent that was unlocked. LPA also observed bleach and other chemicals in the garage that were unlocked. LPA observed sufficient seating under covered patio area in the back of the facility. Backyard gate was self-latching and self-closing. Carbon monoxide and smoke alarm detectors installed and operational. At 1:49 LPA reviewed resident’s medication with the MARs. Facility did not have a Centrally Stored List for any residents. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Frill Drill records were not available. Staff files were reviewed for good health. Staff files had First Aid training. Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.......Continued to next page........

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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: WESSON ARF, LLC	FACILITY NUMBER: 107209238
	VISIT DATE: 06/20/2023

NARRATIVE

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LPA is requesting the following documents be submitted to the Fresno CCL office by 7/5/2023: 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 (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

Exit interview was conducted. Report signed on-site; printed copy of report 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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2023 03:26 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: WESSON ARF, LLC	FACILITY NUMBER: 107209238
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2, LPA observed laundry detergent and bleach unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	Licensee to remove chemicals and lock immediately and designate a locked cabinet/drawer that is more convenient and will be used by staff.

Type A

Section Cited

CCR

80075(k)(7)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: 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 3 out of 3 residents’ medications were not logged in centrally stored list which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Licnesee to ensure record of centrally stored prescription medications which is retained for at least one year and includes the following: (A) The name of the client for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E)The prescription number and the name of the issuingpharmacy. (F) Expiration date. (G) Number of refills. Licensee to submit copies of Centrally Stored list for all residents to CCL

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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 06/20/2023 03:26 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: WESSON ARF, LLC	FACILITY NUMBER: 107209238
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 4 rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/04/2023
	Plan of Correction
1 2 3 4	Licensee will ensure rooms are clean on a continuous basis. Once room is cleaned Licensee will submit pictures to CCL

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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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