157206741-5-22-2024-24-AS-MYAG-D5HSN9-20240522140110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157206741
Report Date: 05/22/2024
Date Signed: 05/22/2024 02:01:39 PM

Document Has Been Signed on 05/22/2024 02:01 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:	COMFORT CARE HOME IV		FACILITY NUMBER:	157206741
ADMINISTRATOR:	DHILLON, AMARDEEP (AMY)		FACILITY TYPE:	740
ADDRESS:	4917 AU CHOCOLAT DR		TELEPHONE:	(661) 204-4455
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	6	CENSUS: 5	DATE:	05/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Amy Dhillon, Licensee		TIME COMPLETED:	02:15 PM

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On 05/22/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA arrived, greeted, and allowed entry by Licensee Amy Dhillon. LPA conducted tour with Licensee. All five residents were present during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 34.9 degrees F and freezer temperature at -2 degree F. Fire extinguisher was observed with a service date of: 03/07/24. Medications were checked and observed kept locked in laundry room cabinet. Residents’ MARS was reviewed. Knives and medication cups observed in kitchen drawers accessible to residents.

Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms were properly equipped, and the hot water temperature was tested range between 107.2 and 107.5 degrees F in shared bedroom and 108.1 in bathroom. Carbon monoxide and smoke detectors were tested and observed to be operational. Outside of facility toured. Side gate was self-closing and self-latching. All residents’ and a sample of staff files were reviewed to have all the required documents.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. LPA received copies of Lic 308, Lic 500, Lic 610E, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of these report.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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 05/22/2024 02:01 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: COMFORT CARE HOME IV	FACILITY NUMBER: 157206741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)

The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when knives and medication cups fill with medications were stored in malfunction kitchen drawers this poses an immediately health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2024
	Plan of Correction
1 2 3 4	Licensee immediately removed knives and medication cups into functioned locked kitchen shelf.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

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