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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206735
Report Date: 04/28/2023
Date Signed: 06/14/2023 09:08:22 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/24/2023 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230424162614
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: 4DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee/Administrator Cristina Zamora & Shift Supervisor Melissa ZamoraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility does not have a qualified Administrator
Staff are retaining residents who require a level of care beyond the scope of the license
INVESTIGATION FINDINGS:
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On 4/28/23 at 9:45 a.m. Licensing Program Analysts (LPAs) B. Miranda & S. Doucette arrived at the facility unannounced to investigate a complaint. LPAs were greeted by Licensee Christina Zamora and Shift Supervisor Melissa Zamora. LPAs were allowed entry into the facility. LPAs explained the reason for the visit.

1. The Department investigated the allegation: Facility does not have a qualified Administrator. After interviewing Licensee/Administrator and reviewing files it was verified the current Administrator Certificate is expired.

2. The Department investigated the allegation: Staff are retaining residents who require a level of care beyond their scope of the license. LPA reviewed R1 records and observed R1 who was not able to complete ADL (Activities of Daily Living).

See LIC9099C for continuation of this report


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20230424162614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/28/2023
NARRATIVE
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The following records were obtained during the visit: Notary Agreement Letter.

LPAs requested the following documentation: Administrator paperwork, updated medical report. Documentation will be due by end of business day 5/12/2023.

Exit interview conducted and copy of this report provided to Shift Supervisor Melissa Zamora.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20230424162614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2023
Section Cited
CCR
87615(a)(5)
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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.
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Licensee/Administrator will speak to family of R1. By end of business day of 5/12/23 plan of arrangement for R1's prohibited health condition.
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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 has a prohibited health condition, which requires staff to preform all activities of daily living.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20230424162614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
87405(a)
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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.
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Licensee/Administrator will submit documentation for a temporary Administrator to be at the facility.
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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.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4