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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206719
Report Date: 12/14/2022
Date Signed: 02/16/2023 08:48:53 AM


Document Has Been Signed on 02/16/2023 08:48 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/16/2023 06:28 AM

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

NARRATIVE
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This is an amended report.

On 12/14/22 at 9 AM, Licensing Program Analyst (LPA) Malia Thao conducted a case management – deficiencies inspection. LPA met with Licensee (LIC) Cathy Malone. LIC was informed that during the course of the recent unsubstantiated complaint investigation, LPA observed the following deficiencies:

1. S1 does not have a completed criminal record clearance according to the Department’s Guardian system however it was observed on the staff schedule, that S1 worked 15 days in total. LIC provided documentation to LPA, subsequent to the inspection, that the Department mailed to her, which lists S1 as cleared. This discrepancy is currently under review by the Department and a deficiency is not being cited however LIC was informed that she cannot allow S1 to work until she can verify in writing in the Guardian system, that S1 has a criminal record clearance and is associated to the facility. LIC was also informed that she is required to have complete files for staff, made available during an inspection, upon request. Licensee’s signature on this report serves as her acknowledgement of this discussion and her agreement to comply.

2. LIC did not have a written agreement with the licensed Home Health Agency for R1 and LIC admitted LIC has never obtained written agreements from the Home Health Agencies for any prior residents receiving Home Health services.

3. S2 did not have a health screening or TB test results.

Deficiencies are being cited based on interview and records review conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. Due to technical difficulties, a copy of this report was emailed to Licensee's email on file. LIC confirmed email has not changed. (Noted 2/16/23: Licensee not present for amended report and granted staff to sign.)

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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 is an Amendment of Original Document on 02/17/2023 08:30 AM

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: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2022
Section Cited

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(AMENDED TO DELETE THIS DEFICIENCY)87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
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(AMENDED TO DELETE THIS DEFICIENCY) LIC will submit a written plan for procedure LIC will follow when hiring new staff, to include a checklist, to ensure staff has a completed criminal record clearance and is associated to the facility prior to working the new staff in the facility, to CCL by POC due date.
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(AMENDED TO DELETE THIS DEFICIENCY)S1 does not have a completed criminal record clearance. S1 was identified on the staff schedule given by LIC. LIC advised LIC uses the staff schedule document, provided to LPA, for payroll, or as the document used to confirm hours worked by staff in order to pay staff. S1 is listed as having worked 15 days in total, between the dates of 6/30/22 through to 8/5/22. Which poses an immediate health, safety, or personal rights risk to residents in care.
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Type B
12/21/2022
Section Cited

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87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).

This requirement is not met as evidenced by:
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Licensee will submit proof of signed in-service training for LIC of CCR Section 87609 to CCL by POC due date. LPA provided a copy of CCR 87609 to LIC via email.
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LIC did not have a written agreement with the licensed Home Health Agency for R1 and LIC admitted LIC has never obtained written agreements from the Home Health Agencies for any prior residents receiving Home Health services, which poses a potential health 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: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/14/2022 10:38 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: PARK RCFE, THE
FACILITY NUMBER: 157206719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2023
Section Cited

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87411 Personnel Requirements – General
(f) All personnel...shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test...

This requirement is not met as evidenced by:
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Licensee will submit proof of health screening and TB test results for S2 to CCL by POC due date.
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S2 did not have a health screening or TB test results, which poses a potential health, safety, or personal rights risk in 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: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3