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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206735
Report Date: 06/16/2023
Date Signed: 06/21/2023 05:07:15 PM


Document Has Been Signed on 06/21/2023 05:07 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:RIDGECREST HOME CAREFACILITY NUMBER:
157206735
ADMINISTRATOR:ZAMORA, CRISTINAFACILITY TYPE:
740
ADDRESS:1028 KINNETT AVENUETELEPHONE:
(760) 463-1180
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:5CENSUS: 3DATE:
06/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee- Cristina ZamoraTIME COMPLETED:
02:00 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 6/16/23 at 12:30 p.m. Licensing Program Analysts (LPAs) B. Miranda and S. Doucette arrived at the facility unannounced. LPAs introduced themselves and explained the reason for the visit was for case management of deficiencies. LPAs asked to speak with the Licensee, who arrived later.

LPAs observed R1 still at the facility with no current hospice plan. Licensee stated R1 had doctor’s appointment on 6/12/23, and family is still selecting hospice provider and deciding if R1 will be put on hospice. Currently hospice has not been selected.

R2 does not have a doctor’s note for postural support. R2 has an appointment set for 7/11/23 and the postural support issue has not been cleared by doctor at this time. LPAs observed R2 who needs total and complete care. LPAs explained to Licensee R2 needs next level of care or a hospice order.

Licensee stated they have not completed the courses to renew AD certificate, S1’s Certificates of Completion for Initial RCFE Certification & LIC9163 were observed by LPAs. S1 has not received Administrator Certificate or background clearance.

Facility previously provided a letter indicating plan of action to clear POCs, at this time verification to clear POCs has not been submitted. POC verification & Dr clearance for Licensee are due by end of business day 6/19/2023.

Citations were issued under Title 22, Division 6, Chapter 8.

Exit interview completed and a copy of this report and LIC809D have been provided to Licensee.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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 2


Document Has Been Signed on 06/21/2023 05:07 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: RIDGECREST HOME CARE
FACILITY NUMBER: 157206735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2023
Section Cited
CCR
87615(a)(5)

1
2
3
4
5
6
7
87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.
1
2
3
4
5
6
7
Licensee will speak to family of R1 & R2 by end of business day of 6/19/23 plan of arrangement for R1 & R2's prohibited health condition.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on LPAs observations, interview, and record reviews, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.LPA observed R1 & R2 to have a prohibited health condition, which requires staff to preform all activities of daily living.
8
9
10
11
12
13
14
Type A
06/19/2023
Section Cited
CCR87405(a)

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
1
2
3
4
5
6
7
Licensee will submit updated documentation for Administrator.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on LPAs observations, interview, and record reviews, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA was informed by Licensee/Administrator the Administrator Certificate has expired.
8
9
10
11
12
13
14
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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2