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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206907
Report Date: 02/09/2023
Date Signed: 02/09/2023 02:39:09 PM

Document Has Been Signed on 02/09/2023 02:39 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:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Administrator Nancy Montiano TIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) K.Kaur conducted an Annual Inspection on this date. LPA met with Administrator Nancy Montiano. LPA and Administrator began the tour at the front entrance/office of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two-day supply of perishable food and seven-day supply of non-perishable food. Cleaning supplies were observed behind a locked door in storage. Personal protective equipment in a storage cabinet in garage. At 1:23 PM LPA observed the laundry room door to be unlocked with a bleach bottle under the sink. Staff records were reviewed for infection control training. LPA observed facility staff without masks. Resident’s files have updated emergency contact information.

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

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/24/2023: 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.

Exit interview was conducted. Report signed on-site; printed copy of report provided with appeal rights.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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 02/09/2023 02:39 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/09/2023 at 02:21 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: 02/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)

80087 Buildings 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 when LPA observed 1 bottle of bleach under the laundry room sink accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Administrator removed the bottle of bleach and placed the bottle in a locked cabinet. Licensee stated that staff will be trained on the requirements of Buildings and Grounds. Evidence of the training will be submitted to the Fresno CCL office by 02/24/2023. POC cleared during visit.
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 Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023


LIC809 (FAS) - (06/04)
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