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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208879
Report Date: 10/22/2024
Date Signed: 10/22/2024 02:24:03 PM

Document Has Been Signed on 10/22/2024 02:24 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:DONNELL COURTFACILITY NUMBER:
157208879
ADMINISTRATOR/
DIRECTOR:		ROSALINDA CUAFACILITY TYPE:
735
ADDRESS:6609 DONNELL CTTELEPHONE:
(661) 412-8548
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:52 AM
MET WITH:Administrator Rosalinda CuaTIME VISIT/
INSPECTION COMPLETED:
02:21 PM
NARRATIVE
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On 10/22/2024, Licensing Program Analyst LPA K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Administrator Rosalinda Cua.

LPA conducted tour with Administrator. Co- Administrator Ronald Duran. The facility was observed to be at a comfortable temperature, clean, in good repair, with no passageway obstructions or fire hazards. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher was observed expired as of 10/2/2023. All common areas were properly furnished and well-lit throughout. Medications are locked in a cabinet in the kitchen. Smoke Alarm and Carbon Monoxide detector tested and operational. LPA toured 4 resident rooms and an office area. All client bedrooms toured and observed to be adequately furnished. Extra linens observed in the cabinet storage in the garage next to laundry area. LPA tested the water temperature in the bathroom at 109 degrees. LPA toured laundry area which appeared clean. Cleaning supplies and chemicals observed locked in cabinet next to laundry. The exterior tour was conducted. The backyard was observed with a locked pool. A shaded area is available to the right of the house for rest and recreation. Medication was reviewed. Staff records were reviewed for good health and training. Clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. At 12:22 LPA observed R1 did not have a current medical assessment and TB Clearance. Last fire drill completed on 12/5/2023.

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

Continued to LIC 809-C
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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 10/22/2024 02:24 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 10/22/2024 at 12:56 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: DONNELL COURT
FACILITY NUMBER: 157208879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 residents were observed to without medical assessment LIC602 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Administrator has scheduled a doctor’s appointment for 10/23/2024 and will send proof of correction by due date.
Type A
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record revie], the licensee did not comply with the section cited above in 1 out of 4 residents were observed without a TB test which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Administrator has scheduled a doctor’s appointment for 10/23/2024 and will send proof of correctionwhen completed.
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: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2024 02:24 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 10/22/2024 at 12:57 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: DONNELL COURT
FACILITY NUMBER: 157208879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)

Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations.

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 in 1 out 1 Fire extinguisher was expired as of 10/2/2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Administrator states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by due date
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: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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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: DONNELL COURT
FACILITY NUMBER: 157208879
VISIT DATE: 10/22/2024
NARRATIVE
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LPA is requesting the following documents be submitted to the Fresno CCL office by 10/29/2024: 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.

An exit interview was conducted with Licensee. Report signed on-site, a copy of report appeal rights will be emailed due to technical difficulties.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
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