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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202387
Report Date: 07/12/2023
Date Signed: 07/12/2023 03:16:12 PM

Document Has Been Signed on 07/12/2023 03:16 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:MOUNTAIN VIEW RANCH RES. CAREFACILITY NUMBER:
157202387
ADMINISTRATOR:NANKIL, PATRICK R.FACILITY TYPE:
735
ADDRESS:3046 HINSLEY STTELEPHONE:
(661) 319-3749
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 4CENSUS: 3DATE:
07/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Administrator Patrick NankilTIME COMPLETED:
03:15 PM
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On 7/12/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Staff. Administrator was contacted and would be assisting with the inspection.

All pathways, entrances and exits were clear from obstructions. LPA and staff began the tour at the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in kitchen was last serviced on 10/04/2022 and was fully charged. Tour continued to the living room which has sufficient seating. LPA toured three resident rooms which were observed to be furnished with required furniture and adequate lighting. At 11:33 AM LPA observed the facility to have dust and cobwebs on walls, ceilings and door farms. LPA observed one resident’s bedroom to have debris on floor. At 12:38 PM LPA observed one resident room to be missing a window screen. Linen supply is kept in the laundry room. Cleaning supplies and chemicals are kept locked in the laundry room and garage. Medications are kept locked in the hallway closet. LPA observed sufficient seating under covered patio area. Backyard gate was self-latching and self-closing. Carbon monoxide and smoke alarm detectors installed and operational. LPA reviewed resident’s medication with the MARs and Centrally Stored List for any residents. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Frill Drill records were reviewed. Staff files were reviewed for good health. Staff files had First Aid training.

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 7/19/2022: 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 Staff. Report signed on-site by staff and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
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 07/12/2023 03:16 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/12/2023 at 02:36 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: MOUNTAIN VIEW RANCH RES. CARE
FACILITY NUMBER: 157202387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 2, LPA observed one of the resident’s room windows to be missing a screen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Licensee will replace/repair window screen and submit proof to CCLD by due date
Type B
Section Cited
CCR
80087(a)


80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 5 out of 5, LPA observed the facility to have dust and cobwebs on walls, ceilings and door farms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Licensee will have the facility cleaned and submit pictures 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: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
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