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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150404353
Report Date: 01/10/2024
Date Signed: 01/11/2024 08:13:54 AM

Document Has Been Signed on 01/11/2024 08:13 AM - 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:ARC-TAFT, THEFACILITY NUMBER:
150404353
ADMINISTRATOR:HAGSTROM, MARYANNFACILITY TYPE:
775
ADDRESS:204 VAN BUREN STREETTELEPHONE:
(661) 763-1532
CITY:TAFTSTATE: CAZIP CODE:
93268
CAPACITY: 45CENSUS: 28DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator Maryann HagstromTIME COMPLETED:
02:00 PM
NARRATIVE
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On 01/10/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual
inspection. LPA introduced self, stated the purpose of the visit and met with Administrator Maryann Hagstrom. LPA completed a tour of the facility with Administrator. Clients were observed in the activity rooms and walking around kitchen.

The facility is maintained at a comfortable temperature and no passageway obstructions or fire hazards were observed. Transportation is available and provided for clients. LPA and Administrator observed cleaning chemical unlock under back bathroom sink and bug spray unlock in the transportation room. Kitchen was toured. Kitchen was toured and observed refrigerator at 40 degrees F. Clients bring their own lunch and snacks to the program. LPA and Administrator observed chemicals under kitchen sink unlock.

LPA observed medications locked in the facility medication room. MARs were reviewed. LPA observed clients’ personal basket in the front entrance. Client bathrooms were tour, observed to be clean, and operational. Hot water temperature was 110.8 degrees F in bathroom 1, 111.1 degrees F in bathroom 2, and 106 degrees F in the back bathroom. Fire extinguishers throughout the facility was observed with served date: 10/25/23. Last fire drill completed on 10/25/23. Chemicals and cleaning supplies were observed locked in the facility laundry room and soda closet. Outside was observed clear of debris. A sample of client files were also reviewed and observed one out of three clients did not have all the required documents. A sample of staff files were reviewed and observed to have all the required documents.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit Interview conducted. The following documents are requested and to be submitted to Fresno CCL by: 01/16/24. The following updated forms were requested: Lic 308, and Lic 610D. A copy of this report and appeal rights was provided to the Administrator, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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 01/11/2024 08:13 AM - It Cannot Be Edited


Created By: Mai Yang On 01/10/2024 at 12:56 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: ARC-TAFT, THE
FACILITY NUMBER: 150404353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(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 observation, the licensee did not comply with the section cited above, when LPA and Administrator observed at approximately 10:43AM, two cleaning chemical bottles in the back bathroom and one bug spray in the transportation room unlock. At approximately 10:54AM, LPA and Administrator observed chemical bottles under kitchen sink unlock while clients were walking around the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Administrator immediately removed the chemical bottles into locked room. POC cleared during inspection.
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 Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/11/2024 08:13 AM - It Cannot Be Edited


Created By: Mai Yang On 01/10/2024 at 12:57 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: ARC-TAFT, THE
FACILITY NUMBER: 150404353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative,
if any.

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 LPA reviewed one out of three clients’ file to not have an Admission Agreement which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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The facility shall ensure that all clients have an Admission Agreement on file at all times. C1’s Admission agreement shall be submitted to the department by 01/19/24
Type B
Section Cited
CCR
82069(a)
Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan

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 LPA reviewed C1's file and observed C1's facility admission date was 08/15/22 and client does not have a physician report (Lic 602) on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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The facility shall ensure that all clients have a physician report completed prior to clients being acceptance to the facility or within 30 days after the client’s acceptance. Client 1’s Lic 602 shall be submitted to the department by 01/19/24.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024


LIC809 (FAS) - (06/04)
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