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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206907
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:30:05 PM

Document Has Been Signed on 07/26/2023 02:30 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:UNION VILLAFACILITY NUMBER:
157206907
ADMINISTRATOR:MONTIANO, NANCYFACILITY TYPE:
735
ADDRESS:1102 S. UNION AVE.TELEPHONE:
(661) 323-0768
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 89CENSUS: 65DATE:
07/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Administrator Nancy MontianoTIME COMPLETED:
02:45 PM
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On 7/26/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct a 10-Day initial complaint visit and conducted a facility tour. The following case management with deficiencies were noted.

LPA observed during the facility tour several residents’ rooms to having missing or dirty bedding. LPA observed Windows that were broken and window screens that were broken or ripped. LPA also observed several rooms to have dust and dirt caked onto walls, doors, fixtures, and furniture. Cobwebs were observed in several resident rooms. LPA observed debris on bedroom floors.

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

An exit interview was conducted with Administrator discussing the plan of corrections. Report signed on-site by Administrator; printed copy provided with 809D page and appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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 07/26/2023 02:30 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/26/2023 at 01:26 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: UNION VILLA
FACILITY NUMBER: 157206907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
80088(b)

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80088 Furniture, Fixtures, Equipment, and Supplies b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
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Administrator agrees to replace/repair all window screens that are damaged and submit pictures to CCLD by due date.
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Facility was observed with screens that were not in good repair.
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Type B
08/25/2023
Section Cited
CCR85088(4)(A)

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85088 Fixtures, Furniture, Equipment and Supplies (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillowcases; .... (A) The quantity of linen provided shall permit changing the linen at least once each week or more often when necessary to ensure that clean linen is in use by clients at all times.
This requirement is not met as evidenced by:
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Administrator to ensure all residents have bedding and ensure it is in clean and good repair and submit pictures to CCLD by due Date
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Residents bedding was not present or was not clean linen and in good repair.
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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: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/26/2023 02:30 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/26/2023 at 01:47 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: UNION VILLA
FACILITY NUMBER: 157206907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
80087(a)

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80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Administrator is to ensure all residents rooms, including fixtures, furniture, walls & ceilings are cleaned. Administrator to submit pictures to CCLD by due date.
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Facility was observed to have dust and dirt caked onto walls, doors, fixtures, and furniture. Cobwebs were observed in several resident rooms.
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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: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


LIC809 (FAS) - (06/04)
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