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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208892
Report Date: 09/21/2023
Date Signed: 09/22/2023 03:30:25 PM

Document Has Been Signed on 09/22/2023 03:30 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:SAILS VIFACILITY NUMBER:
157208892
ADMINISTRATOR:BARNHARD, RAYMONDFACILITY TYPE:
735
ADDRESS:10117 ST ALBANS AVETELEPHONE:
(661) 473-2340
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 5CENSUS: 5DATE:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator Jessica DelgadilloTIME COMPLETED:
12:50 PM
NARRATIVE
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Amended Report

On 09/21/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual
Inspection. LPA introduced self, stated the purpose of the visit, and met with Administrator Jessica Delgadillo. LPA toured facility with Administrator. One client was present during the inspection in the client's room.

The tour started in the common areas into the kitchen to the client’s rooms. The facility was observed to be at a comfortable temperature at 72 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside.



Fire extinguisher was observed with a service date of: 08/10/23. Fire drill last completed on 0916/23. Cleaning chemicals was observed stored and locked in the garage cabinet. Medications were checked and observed kept locked in kitchen closet. Clients’ MARS was reviewed. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -10 degrees F and refrigerator temperature was maintained at 30 degrees F.

Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and
adequate lighting. All bathrooms are toured. Hot water temperature was tested 109 degrees F. in bathroom 1 and range between 111.7 and 111.9 degrees F. in master bathroom.

Outside of facility toured. Side gate was self-closing and self-latching. All clients’ file reviewed to have update Emergency contacts, Admission agreement, IPP, and physician report. LPA reviewed three staff files to have current First Aid/CPR, Personnel Record, Criminal record Statement, and Health Screening. Carbon monoxide and smoke detectors were tested and observed to be operational.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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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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: SAILS VI
FACILITY NUMBER: 157208892
VISIT DATE: 09/21/2023
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Amended Report

No deficiency cited during inspection

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 09/27/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610D, Lic 9282, current Administrator Certificate, and control of property. LPA received copy of current Administrator certificate, update facility sketch, and current liability insurance. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 09/22/2023 03:20 PM


Created By: Mai Yang On 09/21/2023 at 12:13 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SAILS VI
FACILITY NUMBER: 157208892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance…

This requirement is not met as evidenced by:


Deficient Practice Statement
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Staff 1 whose not associated to the faciity has been working at the facility 40 hours a week, 5 days a week provide care and supervision for clients which poses an immediate risk to the health and safety of the residents.

POC Due Date: 09/22/2023
Plan of Correction
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Staff 1 left facility during inspection. Staff is not permitted back until associated. 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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
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