157203989-5-24-2023-24-AS-MYAG-CS5UZN-20230524160146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157203989
Report Date: 03/06/2023
Date Signed: 05/24/2023 04:02:58 PM

Document Has Been Signed on 05/24/2023 04:02 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:	PHASE TWO SERVICES CORP.		FACILITY NUMBER:	157203989
ADMINISTRATOR:	GONZALEZ, JESUS		FACILITY TYPE:	735
ADDRESS:	9500 THOREAU AVENUE		TELEPHONE:	(661) 282-3183
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY: 4		CENSUS: 4	DATE:	03/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Administrator Jesus Gonzalez		TIME COMPLETED:	11:00 AM

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On 3/6/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Administrator Jesus Gonzalez. LPA conduct tour with Administrator. One client was present during the inspection.

The tour started in the common areas into the kitchen, client's rooms, and bathrooms. LPA observed COVID-19 related signs. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Refrigerator temperature maintained at 40 degrees F and freezer temperature at 0-degree F. Cleaning supplies and chemicals are kept in locked in garage cabinet. An adequate supply of perishable and non-perishable food was observed to be properly stored and labelled. At approximately 08:43AM, observed chemicals were observed stored in unlock shelf in laundry room. Laundry area was observed to be operational.

Fire extinguisher was observed with a service date of: 08/24/22. Clients' bedrooms were toured next and observed to be adequately furnished with bed, dresser, and adequate lightning. Bathrooms were properly equipped, and the hot water temperature was tested at 116.2 and 120 degrees F in master bathroom. Trash can with lid and hand washing postings was observed. Medications are kept locked in hall closet. Outside of facility toured. Exterior toured and LPA observed side gate to be self-closing and free of debris.

All clients’ file reviewed to have update emergency contacts, Admission agreement, and Pre-Appraisal forms. All of staff's files were also reviewed. Staff files were observed to have current First Aid/CPR. Staff are fingerprinted clear and associated to the facility. Fire drill last completed on 1/20/23. Carbon monoxide and smoke detectors were tested and observed to be operational. First aid kit was observed and contained all required items.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

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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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: PHASE TWO SERVICES CORP.	FACILITY NUMBER: 157203989
	VISIT DATE: 03/06/2023

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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 and submitted to Fresno CCL by: 3/13/23. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610D, Lic 9020, control of property, and current Administrator certificate. A copy of this report and appeal rights was provided to Administrator.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/24/2023 04:03 PM - It Cannot Be Edited

Created By: Mai Yang On 03/06/2023 at 10:07 AM

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: PHASE TWO SERVICES CORP.	FACILITY NUMBER: 157203989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Buildings and Grounds Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, when LPA and Administrator observed at approximately 08:43AM, laundry detergents and cleaning bottle stored in unlock shelf above washer and dryer in the laundry room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2023
	Plan of Correction
1 2 3 4	Administrator immediately removed laundry detergents and cleaning bottles into lock cabinet in the garage. POC cleared during visit.

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 Moua

LICENSING EVALUATOR NAME:

Mai Yang

LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC809 (FAS) - (06/04)

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