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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150404353
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:00:48 PM

Document Has Been Signed on 10/03/2024 12:00 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:ARC-TAFT, THEFACILITY NUMBER:
150404353
ADMINISTRATOR/
DIRECTOR:		HAGSTROM, MARYANNFACILITY TYPE:
775
ADDRESS:204 VAN BUREN STREETTELEPHONE:
(661) 763-1532
CITY:TAFTSTATE: CAZIP CODE:
93268
CAPACITY: 45CENSUS: 29DATE:
10/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Administrator Maryann HagstromTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 10/03/24, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced initial complaint investigation and met with Administrator Maryann Hagstrom.

During the course of the investigation, there were two incident that had occurred on 08/26/24 and on 09/27/24, where C1 was left unattended by staff. The facility did not report written incident for the two incidents to the department.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6. An immediate civil penalty is not being cited as the allegation was substantiated in complaint # 24-AS-20240930100339 and a deficiency was cited in that complaint.

Exit interview conducted. A copy of this report and appeal rights was provided to Administrator, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/03/2024 12:00 PM - It Cannot Be Edited


Created By: Mai Yang On 10/03/2024 at 11:23 AM
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: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2024
Section Cited
CCR
82061(a)(1)(D)

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82061 (a)(1)(D) Upon the occurrence, during the hours the day program is providing services to the client, of any of the events specified in Section 82061(a)(1), a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in Section 82061(a)(2) shall be submitted to the licensing agency within seven days following the occurrence of the event. (1) Events reported shall include, but not be limited to, the following: (D) Any unusual incident which threatens the physical or emotional health or safety of any client;

This requirement was not met as evidenced by:
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Licensee agrees to submit a plan detailing steps the facility will take to ensure the requirements of Reporting requirements are met by the POC due date of 10/09/24.

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Based on record review and interview, the facility did not ensure a written incident report was submitted to the department within 7 days of occurrence that had occurred on 08/26/24 and 09/27/24 where C1 was unattended by staff, this poses a potential health and safety risk to residents in care.
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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: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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