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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202422
Report Date: 02/16/2024
Date Signed: 02/20/2024 08:44:15 AM


Document Has Been Signed on 02/20/2024 08:44 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:MOUNTAIN VISTA SENIOR CAREFACILITY NUMBER:
157202422
ADMINISTRATOR:HUNT, DANIELFACILITY TYPE:
740
ADDRESS:20001 PIEDRA DRIVETELEPHONE:
(661) 822-3556
CITY:TEHACHAPISTATE: CAZIP CODE:
93561
CAPACITY:6CENSUS: 4DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Desginee Teresa Fraser and Licensee Daniel HuntTIME COMPLETED:
02:30 PM
NARRATIVE
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On 2/16/24, 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. LPA met with Desginee Teresa Fraser. Licensee Daniel Hunt was called, greeted LPA, and left during inspection. All four residents were present during the inspection.

The tour started in the kitchen into the common areas to the residents’ rooms. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Sharps observed locked under kitchen counter. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 37 degrees F and freezer maintained at 0 degree F. Fire extinguisher was observed with a service date of: 05/3/23. Cleaning chemicals observed locked in laundry room. Medications were checked and observed kept locked in laundry room. Residents’ MARS were reviewed. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested 112.4 degrees F. in bathroom 1, 112.4 degrees F. in bathroom 2, and 111.5 degrees F in master bathroom. Outside of facility toured and observed free of debris. Adequately seating was observed outside for resident. Side gate was self-closing and self-latching. All resident and staff files reviewed to have all the required documents. Carbon monoxide and smoke detectors were tested and observed to be operational.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 02/23/24. The following updated forms were requested: Lic 308, Lic 309, Lic 610E, and current liability insurance. LPA received a copy of Lic 500, and current Administrator certificate. A copy of this report and appeal rights was provided to Designee, whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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 02/20/2024 08:44 AM - 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: MOUNTAIN VISTA SENIOR CARE
FACILITY NUMBER: 157202422

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465 (c) (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on interviews and records review, LPA and S1 observed in R1’s MARs, Multi-Vitamins doctor order to take one 1 tablet daily. Medication was documented administered daily for the whole month of February. Medication had not been in stored for the month of February while documentation stated was administered to resident which poses an immediate health and safety risk for the person in care.
POC Due Date: 02/17/2024
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 02/17/24.

Licensee shall have all staff retrained Health-Related Services regulations 87465. Licensee will submit documentation of training topics which include process of administering medications with staff attendance rooster to the Fresno CCL office by 02/23/24.
Type A
Section Cited
HSC
1796.45(d)
1796.45(d) TB Testing (d) After each examination, an affiliated home care aide shall submit, and the home care organization shall keep on file, a certificate from the examining practitioner showing that the affiliated home care aide was examined and found free from active tuberculosis disease.

This requirement was not met as evidenced by:

Deficient Practice Statement
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Based on record reviewed, LPA reviewed all staff files and observed S1 did not have a TB result on file which poses an immediate health and safety of the residents in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee shall ensure all staff have a TB result on file. S1 TB result shall be submitted to the Fresno CCL office by POC due date 02/19/24.
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 MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document is an Amendment of Original Document on 02/20/2024 02:27 PM

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: MOUNTAIN VISTA SENIOR CARE
FACILITY NUMBER: 157202422

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
87458 (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602..., Physician's Report, to obtain the medical assessment.

This requirement was not met as evidenced by:

Deficient Practice Statement
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Deficiency cleared, Lic 602A was on file.
POC Due Date: 02/20/2024
Plan of Correction
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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 MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4