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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206719
Report Date: 11/16/2022
Date Signed: 11/16/2022 12:17:17 PM


Document Has Been Signed on 11/16/2022 12:17 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:PARK RCFE, THEFACILITY NUMBER:
157206719
ADMINISTRATOR:MALONE, CATHYFACILITY TYPE:
740
ADDRESS:311 GARNSEY AVENUETELEPHONE:
(661) 283-4160
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:9CENSUS: 5DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Cathy Malone, Licensee/AdministratorTIME COMPLETED:
12:40 PM
NARRATIVE
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On 11/16/22 at 11:20 AM, Licensing Program Analyst (LPA) Malia Thao conducted a case management - deficiencies inspection. LPA was present for an inspection for complaint #24-AS-20220817155043 and discovered deficiencies. LPA met with Licensee/Administrator (LIC) Cathy Malone.

On 8/9/22, R1 tested positive for COVID-19. Following that, three additional residents and two staff tested positive for COVID-19. LIC did not report COVID-19 positive residents and staff to CCL.

On 8/15/22, R1 was sent out to the hospital. LIC admits an incident report was not submitted to CCL for reporting.

LPA advised a Special Incident Report for each incident is to be submitted to CCL by 11/21/22. LPA advised the annual fees are now past due as of 11/8/22 and can be paid online. LIC advised it will be paid by 11/18/22.

A deficiency is being cited based on LPA interview in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted and a Plan of Correction was developed and reviewed with Licensee. A copy of this report and appeal rights were given to Licensee, whose signature confirms receipt of this report.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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 11/16/2022 12:17 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: PARK RCFE, THE
FACILITY NUMBER: 157206719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

This requirement is not met as evidenced by:
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On 8/9/22, R1 tested positive for COVID-19. Following that, three additional residents and two staff tested positive for COVID-19. LIC did not report COVID-19 positive residents and staff to CCL. On 8/15/22, R1 was sent out to the hospital. LIC admits an incident report was not submitted to CCL for reporting. Which poses a potential health, safety, or personal rights risk to residents 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: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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