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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406456
Report Date: 08/29/2024
Date Signed: 09/10/2024 08:12:09 AM

Document Has Been Signed on 09/10/2024 08:12 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:CENTRE VILLAGEFACILITY NUMBER:
150406456
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ LOPEZ, NORAFACILITY TYPE:
735
ADDRESS:2500 GOSFORD ROADTELEPHONE:
(661) 836-2500
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 76CENSUS: 55DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:52 AM
MET WITH:Administrator Nora Rodriguez LopezTIME VISIT/
INSPECTION COMPLETED:
09:45 PM
NARRATIVE
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On 8/29/2024 Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. LPA met with Administrator Nora Rodriguez Lopez. Tour was conducted together.

LPA toured a sample of apartment units; one apartment on each floor of each apartment building. Facility has 7 buildings with apartments on the first floor and second floor. Each building observed with a evacuation chair. Each building was observed to be at a comfortable temperature, clean, in good repair, with no passageway obstructions or fire hazards. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguishers were observed in each apartment with a service date of 10/3/2023 and was fully charged. All common areas were properly furnished and well-lit throughout. Medications, First Aid, and Sharp items are locked in each apartment in the kitchen cabinets. Smoke Alarms were tested in 5 out of 12 apartments and were operational. LPA observed Carbon Monoxide detectors in 2 units that were tested and operational. Grounds were toured, covered seating observed under patio umbrellas. Two pools observed gated and locked. Activities room was toured.

The following deficiencies were observed:

1. LPA observed the following unlocked chemicals.
At 1:24PM Cleaning supplies and laundry soap on a housekeeping cart outside of apartment number #111.
At 3:35PM Comet cleaner and Hydrogen Peroxide Cleaner observed unlocked in activities building.
At 3:41PM Laundry powder and laundry pods observed unlocked in resident laundry room.

2. In apartment units #111 and 612, the hot water measured 121.6 degrees F and 132.4 degrees F.

Continued on LIC809-C.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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 4
Document Has Been Signed on 09/10/2024 08:12 AM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 08/29/2024 at 07:49 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: CENTRE VILLAGE
FACILITY NUMBER: 150406456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

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
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Based on observation, the licensee did not comply with the section cited above in 8 out of 8 common areas and resident apartments were observed with unlocked chemicals which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Administrator had all chemicals locked and removed from common areas during inspection. Administrator agrees to provide in service training to all staff and submit documents when completed.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 2 out of 14 Apartments were observed to have water that was above 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Administrator agrees to adjust water heater temperatures for said apartments to bring water temperatures within compliance of 105 to 120.
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:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/10/2024 08:12 AM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 08/29/2024 at 07:50 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: CENTRE VILLAGE
FACILITY NUMBER: 150406456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 2 resident's response was not documented to PRN medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Administrator agrees to provide In-Service training to all Medication staff and submit documents of training to CCLD by due date.
Type B
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
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Based on observation, interview and, record review, the licensee did not comply with the section cited above in 2 out of residents Centrally Stored Medication log was incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Administrator agrees to have all medication records audited and complete missing information on Centrally Stored Medication and Destruction Record (CSMDR) and complete in service training and provide copies of training and 5 resident’s CSMDR records 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 Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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: CENTRE VILLAGE
FACILITY NUMBER: 150406456
VISIT DATE: 08/29/2024
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3. Apartment unit #111, 121, 512, 522, 623 did not have a carbon monoxide detector installed.

4. Medication audit and review of Medication, Centrally Stored Medication Log, and MARs had incomplete Centrally Stored Log, PRN medication that was not documented with residents’ response.



Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 9/5/2024: 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.

An exit interview was conducted with Administrator. Corrections were discussed. Report signed on-site; a printed copy was provided including appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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