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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206769
Report Date: 09/18/2023
Date Signed: 09/18/2023 03:22:39 PM

Document Has Been Signed on 09/18/2023 03:22 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:SAILS RANCHOFACILITY NUMBER:
157206769
ADMINISTRATOR:MARQUEZ, BERTAFACILITY TYPE:
735
ADDRESS:4644 WYATT STTELEPHONE:
(760) 547-7626
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 4CENSUS: 4DATE:
09/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Jose Marquez TIME COMPLETED:
03:00 PM
NARRATIVE
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On 9/18/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced and conducted a case management – deficiencies visit in regards to a self-reported incident that occurred on 02/02/2023.

Based on incident report Resident (R1) observed an unattended knife left on the kitchen counter while staff were cooking and stabbed Resident (R2). LPA interviewed Administrator (AD) and reviewed Residents facility file and gathered copies of documents. The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

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

An immediate Civil Penalty of $500 is issued. An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided with appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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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Document Has Been Signed on 09/18/2023 03:22 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 09/18/2023 at 02:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SAILS RANCHO
FACILITY NUMBER: 157206769

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2023
Section Cited
CCR
85065(b)

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85065 Personnel Requirements (b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirement was not met as evidenced by:
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Licensee to complete training with staff to ensure sharps are not left unattended even while in use. Licnesee to ensure sufficient staff is present to provide care and supervision.
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Resident was left unattended with a sharp; causing harm to resident 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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023


LIC809 (FAS) - (06/04)
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