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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206875
Report Date: 04/12/2024
Date Signed: 04/12/2024 01:45:08 PM


Document Has Been Signed on 04/12/2024 01:45 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:DEVOTED HOME CARE, LLCFACILITY NUMBER:
157206875
ADMINISTRATOR:AGUIL, AMILYNFACILITY TYPE:
740
ADDRESS:10106 COBBLESTONE AVENUETELEPHONE:
(661) 858-0862
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator Petro CrisostomoTIME COMPLETED:
02:00 PM
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On 04/12/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met caregiver Jane “Jackie” Corral. LPA toured facility with caregiver. Licensee/Administrator Petro Crisostomo was called and arrived shortly during tour. 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 or outside. Medications were observed locked in medication cart in the dining area. MARs were reviewed. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 40 degrees F and freezer at 0 degrees F. Fire extinguisher was observed with a service date of: 01/29/24. Cleaning supplies and chemicals stored and locked in garage and laundry room. Dryer observed operational during inspection.

All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested range at 108 and 109.4 degrees F in master bathroom and 119.4 degrees F in bathroom. Extra linens were observed. All residents and sample of staff files were observed with the required documents. Outside of facility toured and observed to be free of debris.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 4/18/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, current Administrator certificate, and control of property. A copy of this report and appeal rights was provided to Administrator, 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: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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 04/12/2024 01:45 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: DEVOTED HOME CARE, LLC
FACILITY NUMBER: 157206875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on interviews and records review, the licensee did not ensure staff administer medications residents as prescribed by physicians, which poses an immediate health and safety risks to persons in care.
POC Due Date: 04/13/2024
Plan of Correction
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A written action plan the facility will take to ensure regulations is met at all times shall be submitted to CCL. POC of action plan will be submitted to department by 04/13/24.
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: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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