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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203951
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:07:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/16/2023 12:07 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:ST. CATHERINE'S HOME CARE, INC.FACILITY NUMBER:
157203951
ADMINISTRATOR:NECER, AMALIAFACILITY TYPE:
740
ADDRESS:10214 PINNACLE RIDGE AVE.TELEPHONE:
(661) 665-9405
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
05/16/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Amalia NecerTIME COMPLETED:
12:20 PM
NARRATIVE
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On 05/12/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry. LPA met with Administrator Amalia Necer.

LPA reviewed a sample of staff files. Two out of four staff file reviewed to have current First Aid/CPR certification.

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

The following documents are requested and submitted to Fresno CCL by: 5/25/23. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 9282, current Administrator Certificate, and current liability insurance.A copy of this report and appeal rights was discussed and provided to Administrator, whose signature on this form confirms receiving this report.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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 05/16/2023 12:07 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: ST. CATHERINE'S HOME CARE, INC.
FACILITY NUMBER: 157203951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
CCR
87412(a)

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87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement was not met as evidenced by:
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Licensee shall ensure all required personnel documents for all staff are maintained in the facility by 5/31/23.
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Based on observation, Administrator was able to provide for review the staff First Aid/CPR certification for two staff out of the four staff. Administrator did not have additional personnel records for the facility staff. This poses a potential health, safety or personal rights risk to persons 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 MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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