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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206776
Report Date: 06/17/2024
Date Signed: 06/17/2024 02:15:54 PM

Document Has Been Signed on 06/17/2024 02:15 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:EUCALYPTUS HOUSEFACILITY NUMBER:
157206776
ADMINISTRATOR/
DIRECTOR:		GREENHALGH, STELLAFACILITY TYPE:
735
ADDRESS:7708 SPROAT WAYTELEPHONE:
(661) 282-5687
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 3DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Misty VeaseyTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 6/17/2024, Licensing Program Analyst LPA K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Administrator Misty Veasey.

LPA conducted tour with administrator. The facility was observed to be at a comfortable temperature, clean, in good repair, with no passageway obstructions or fire hazards. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the Kitchen was last serviced on 2/7/2024 and was fully charged. All common areas were properly furnished and well-lit throughout. Medications are locked in the storage unit in the office area. Sharps are kept in the cabinet in the kitchen. Smoke Alarm and Carbon Monoxide detector tested and operational.

LPA toured 3 resident rooms. Resident did not open 4th bedroom door to allow tour. Toured bedrooms observed to be adequately furnished. Extra linens observed in the hallway drawers. LPA toured two bathrooms. LPA toured laundry area which appeared clean. LPA observed laundry soap to be left unlocked in the laundry area. First aid, tools and other items locked in cabinets next to laundry. Cleaning supplies and chemicals observed locked in the garage. The exterior tour was conducted. The backyard was observed to have sufficient. A covered area is provided during the summer. Both Backyard gate was self-latching and self-closing. Medication was reviewed. Staff records were reviewed for good health and training, all clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. Last fire drill completed on 6/14/2024. At 1:15 PM LPA observed during records review Centrally stored log was incomplete for 2 residents out of 3.

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

Continued to Next Page
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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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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: EUCALYPTUS HOUSE
FACILITY NUMBER: 157206776
VISIT DATE: 06/17/2024
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LPA is requesting the following documents be submitted to the Fresno CCL office by 6/24/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. Report signed on-site; a printed copy was provided including appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 02:15 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 06/17/2024 at 02:01 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: EUCALYPTUS HOUSE
FACILITY NUMBER: 157206776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 laundry detergent was left unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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Administrator to ensure all chemicals remain unlocked at all times. Administrator will submit a statement regarding conducting a in service training and submit by due date. Once all staff have completed in service record of training will be submitted to CCLD. Administrator removed and locked laundry detergent immediately.
Type A
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 residents Centrally Stored Medication Log was incomplete, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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Administrator to update all missing data and submit to CCLD by due date and provide in service training to staff of centrally stored record keeping requirements.
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: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
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