<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203951
Report Date: 05/22/2024
Date Signed: 05/22/2024 05:03:38 PM


Document Has Been Signed on 05/22/2024 05:03 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: 4DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Licensee Amalia NecerTIME COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/22/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA arrived, introduce self, and stated the purpose of the visit. LPA met with staff Beatrice Valentino. Licensee Amalia Necer was called and arrived shortly. LPA conducted tour with Licensee. All four residents were present during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. LPA observed medications stored on kitchen counter accessible to residents. Cleaning chemical was observed stored under kitchen sink unlock. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 35 degrees F and freezer temperature at -1 degree F. Fire extinguisher was observed with a service date of: 05/22/24. Medications were checked and observed kept locked in laundry room cabinet. Residents’ MARS was reviewed. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms were properly equipped, and the hot water temperature was tested range between 110.9 and 111 degrees F in shared bedroom and 110.8 in bathroom. Smoke detectors were tested and observed to be operational. Outside of facility toured. Side gate was self-closing and self-latching. All residents’ and all staff files were reviewed to have all the required documents.



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

Exit Interview conducted. The following documents are requested to be submitted to the department by 05/28/24: Lic 308, Lic 500, Lic 610E, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of these report.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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 5


Document Has Been Signed on 05/22/2024 05:03 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: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705(f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when medications were observed stored on kitchen counter and in resident’s dresser unlock accessible to residents. Cleaning chemicals were observed stored under kitchen sink unlock accessible to residents this poses an immediately health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
1
2
3
4
Licensee immediately removed medications and cleaning chemicals into lock shelf.
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and records review, the licensee did not ensure staff administer medication to resident as prescribed by physicians, which poses an immediate health and safety risks to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
1
2
3
4
All staff in-service trainings on medication shall be completed by the POC due date. Copies of trainings and rooster of all staff attendance will be submitted to department by 05/23/24.
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: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/22/2024 05:03 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: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and observation, facility does not have a carbon monoxide detector which poses a potential health and safety risks to persons in care.
POC Due Date: 05/27/2024
Plan of Correction
1
2
3
4
Licensee shall ensure the facility have a carbon monoxide detector in the facility at all times. Proof of a purchase of a carbon monoxide detector shall be submitted to department by 05/27/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5