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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208254
Report Date: 11/25/2024
Date Signed: 11/25/2024 02:47:47 PM

Document Has Been Signed on 11/25/2024 02:47 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:ADAKCFACILITY NUMBER:
157208254
ADMINISTRATOR/
DIRECTOR:		CAPRA, JANELLEFACILITY TYPE:
775
ADDRESS:4203 BUENA VISTA RDTELEPHONE:
(661) 665-8871
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 100CENSUS: 115DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:23 PM
MET WITH:Administrator Julie Juarez and Executive Director Tamara “Tammy” BakerTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 11/25/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual
inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator.
LPA met Administrator (A1) Julie Juarez and Executive Director (ED) Tamara “Tammy” Baker.

LPA conducted tour with A1 and ED. 12 clients were present during the inspection. Clients were observed in the activity room. Transportation is available and provided for clients. Facility is maintained at a comfortable temperature and no passageway obstructions or fire hazards were observed outside and inside. LPA toured and observed water fountain functional and operational. LPA observed locked medications in medication room in Program Manager office. MARs were reviewed and medication was checked. Client's cubbies were observed in the activity room and near bathrooms. Client restrooms were tour, observed to be clean, and operational. Hot water temperature was ranged between 112.6, 116.3, and 115.3 degrees in bathrooms near activity room and 106.7 degrees in hall bathrooms. Day program prepares meals and snacks for clients in the kitchen. Adequate non-perishable and perishable food were observed. Refrigerator temperature was maintained at 39.4 degrees F and freezer temperature was maintained at -4 degrees. Outside of facility was toured. Adequate outdoor seatings available for clients. Fire extinguishers throughout the facility was observed with served date: 09/11/24. Chemicals and cleaning supplies were observed locked in storage room. A sample of client and staff files were also reviewed to have the required documents.

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

Exit Interview conducted. The following documents are requested and to be submitted to Fresno CCL by:
12/04/24. The following updated forms were requested: Lic 308, Lic 500, and Lic 610D. A copy of this report and appeal rights was provided to Administrator, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 11/25/2024 02:47 PM - It Cannot Be Edited


Created By: Mai Yang On 11/25/2024 at 02:22 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: ADAKC
FACILITY NUMBER: 157208254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)
82087(a)The program site 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:

Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed mold in the ice machine which poses a potential health, safety or personal rights risk to person in care.
POC Due Date: 11/26/2024
Plan of Correction
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Ice machine was cleaned immediately. POC cleared during visit.
Type A
Section Cited
CCR
82075(b)(5)(B)
82075(b)(5)(B) Once ordered by the physician the medication is given according to the physician's directions.

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 C1’s MAR and medications was checked and not accounted for which poses a potential health, safety or personal rights risk to person in care.

POC Due Date: 11/26/2024
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 11/26/24.

Licensee shall have in-service staff training for all staff administering medication to be retrained on administering medications. Licensee will submit documentation of training topics and materials including date, training instructor, and staff attendance rooster to the Fresno CCL office by 12/9/24.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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