107209324-5-28-2024-24-AS-VGON-D5PSS4-20240528140719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209324
Report Date: 05/28/2024
Date Signed: 05/28/2024 02:07:47 PM

Document Has Been Signed on 05/28/2024 02:07 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:	GROVE, THE		FACILITY NUMBER:	107209324
ADMINISTRATOR:	BREWER, NORSHELL		FACILITY TYPE:	740
ADDRESS:	7444 NORTH CEDAR AVE		TELEPHONE:	(801) 815-0808
CITY:	FRESNO	STATE: CA	ZIP CODE:	93720
CAPACITY:	130	CENSUS: 59	DATE:	05/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:09 AM
MET WITH:	Administrator Norshell Brewer		TIME COMPLETED:	01:15 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 05/28/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director (ED) Norshell Brewer, certification number 6030647740 and expiration date 07/16/2024. LPA conducted tour inside and out of facility with ED. Residents were observed at the facility during breakfast and in common areas. The facility was observed to be at a comfortable temperature of 74 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 10/18/2023 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week on Mondays and Wednesdays. Refrigerator temperature was maintained at 43.0-degree F. and freezer was maintained at -6-degree F. LPA toured a sample of resident bedrooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 106 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room and observed chemicals were stored and locked. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Report continues on LIC809-C

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

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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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: GROVE, THE	FACILITY NUMBER: 107209324
	VISIT DATE: 05/28/2024

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Samples of residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan and medication records. Also staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):

· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 06/04/2024

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

No deficiencies issued during this inspection. An exit interview was conducted with the ED.
A copy of this report was given to the ED, whose signature on this form confirm receipt of these reports.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC809 (FAS) - (06/04)

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