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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206726
Report Date: 04/06/2023
Date Signed: 04/06/2023 12:05:56 PM


Document Has Been Signed on 04/06/2023 12:05 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:HERITAGE LIVING IFACILITY NUMBER:
157206726
ADMINISTRATOR:TINA MALHIFACILITY TYPE:
740
ADDRESS:10411 BLYTHE CT.TELEPHONE:
(661) 664-9535
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Administrator Tina Malhi TIME COMPLETED:
12:15 PM
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On 4/6/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA was greeted by Administrator Tina Malhi and granted entry. LPA introduced self and stated the purpose of the visit. All five residents were present during the inspection.

The tour started in the common areas into the kitchen to resident's rooms and bathroom. 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.

Fire extinguisher was observed with a service date of: 06/8/22. Medications are kept locked in kitchen drawer. Temperature tested for refrigerator at 39.4 degree F. and freezer at 10.8 degree F. An adequate supply of perishable and non-perishable food was observed to be properly stored. Cleaning chemicals are kept in locked under kitchen sink. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lightning.

LPA observed 1 shared residents’ bed to be at least 6 feet apart and 3 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. Bathrooms hot water temperature was tested range at 117.3 in bathroom 1. LPA observed trash can with lid and hand washing signs. The exterior tour was conducted. Side gate was self-closing and self-latching.

A sample of the residents’ file reviewed to have update emergency contacts, Admission agreement, and physician report. A sample staff files were also reviewed. Staff files were observed to have current First Aid/CPR, Personal Record, and TB results. First aid kit was observed and contained all required items. Carbon monoxide and smoke detectors were tested and observed to be operational.

No deficiencies issued during this inspection. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 4/12/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, current liability insurance, control property, and current Administrator certificate. A copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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