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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206846
Report Date: 01/04/2024
Date Signed: 01/05/2024 11:06:28 AM


Document Has Been Signed on 01/05/2024 11:06 AM - 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:TEHACHAPI MANORFACILITY NUMBER:
157206846
ADMINISTRATOR:RODRIGUEZ, LORENAFACILITY TYPE:
740
ADDRESS:20400 OAK KNOLL DR.TELEPHONE:
(661) 822-7885
CITY:TEHACHAPISTATE: CAZIP CODE:
93561
CAPACITY:6CENSUS: 3DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lorena Rodriguez, LicenseeTIME COMPLETED:
02:00 PM
NARRATIVE
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On 01/04/24, Licensing Program Analysts (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit and request to meet with Administrator. LPA met with staff Alejandra Gaitan. Licensee Lorena Rodriguez was called and arrived shortly. All three resident was 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 or outside. Temperature maintained for refrigerator at 38.8 degrees F. An adequate supply of perishable and non-perishable food was observed. Fire extinguisher was observed with a service date of: 12/03/2023. Medications observed kept locked in laundry room. MARs were reviewed. Cleaning supplies and chemicals stored and locked in laundry room. Dryer was observed operational during inspection.

All bedrooms were observed to have required furnishings and with adequate lighting. Bathrooms were properly equipped and operational. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested 105.4 bathroom 1, range 111.9 and 112.3 degrees in shared bathroom 2 and range 107.2 and 106.3 degrees F in shared bathroom 3. Outside of facility toured and observed to be free of debris. Outdoor seatings observed available for residents. Smoke detectors were tested and observed to be operational. All residents’ file reviewed to have all the required documents. All staff files were reviewed to have all required documents, fingerprinted clear, and associated to the facility.

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 a copy of Administrator certificate, current liability insurance, and Lic 308. The following documents are requested and submitted to Fresno CCL by: 01/10/24. Forms requested: Lic 500, Lic 610E, and Lic 9020. A copy of this report and appeal rights was provided to the Licensee, whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
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 01/05/2024 11:06 AM - 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: TEHACHAPI MANOR
FACILITY NUMBER: 157206846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)
87705 (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2)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
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Based on observation, the licensee did not comply with the section cited above when LPA and Licensee observed at 10:48 AM, multiple tools on second drawer and one staff medication bottle on the top drawer unlock in the dining counter. At 10:57 AM, LPA and Licensee observed in television stand foot cream bottle and an electrical tool unlock and accessible to residents in care this poses an immediate health, safety or personal rights risk to the residents in care.
POC Due Date: 01/05/2024
Plan of Correction
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Licensee immediately removed the tools and medication into lock laundry room. POC cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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