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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155801189
Report Date: 04/24/2023
Date Signed: 04/24/2023 02:28:54 PM


Document Has Been Signed on 04/24/2023 02:28 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:WESTCHESTER GARDENSFACILITY NUMBER:
155801189
ADMINISTRATOR:JOHNSON, JONATHANFACILITY TYPE:
740
ADDRESS:2228 TRUXTUN AVETELEPHONE:
(661) 324-3091
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY:36CENSUS: 22DATE:
04/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jonathan Johnson, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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On 4/24/23 at 1:00 PM, Licensing Program Analyst (LPA) Malia Thao conducted a case management - deficiencies inspection. LPA explained reason for inspection and met with Administrator (ADM) Jonathan Johnson.

CCL received an incident report from the facility reporting a medication error that occurred on 4/17/23. S1 administered R2's 8 PM medications to R1 in error during the 8 PM med pass.

LPA conducted interviews and reviewed records. ADM advised S1 is no longer employed.

During inspection, LPA found that S2 did not have a completed transfer of criminal record clearance. S2 has been working in the facility since 3/28/23.

Deficiencies are being cited based on LPA observations, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days, for a total of $500 for S2. See LIC421BG for more details.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with Administrator Jonathan Johnson, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
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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Document Has Been Signed on 04/24/2023 02:28 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: WESTCHESTER GARDENS
FACILITY NUMBER: 155801189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2023
Section Cited

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review...shall prior to working, ...in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
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Administrator immediately completed the transfer of criminal record clearance for S2 during the inspection. POC cleared.
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During inspection, LPA found that S2 did not have a completed transfer of criminal record clearance. S2 has been working in the facility since 3/28/23, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type B
05/03/2023
Section Cited

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Administrator will submit proof of an in-service training roster of Medication Administration training given by Mercy Plaza Pharmacy for all staff designated to assist with medication administration, to CCL by POC due date.
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On 4/17/23, S1 administered R2's 8 PM medications to R1 in error during the 8 PM med pass, which poses a potential health or personal rights 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: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
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