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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208938
Report Date: 07/11/2023
Date Signed: 07/11/2023 04:01:30 PM

Document Has Been Signed on 07/11/2023 04:01 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:PURPOSEFUL RESIDENTIAL CARE: ERIE PLACEFACILITY NUMBER:
157208938
ADMINISTRATOR:VICKERS, TYSONFACILITY TYPE:
735
ADDRESS:1308 ERIE STTELEPHONE:
(661) 742-6007
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: 3DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Licensee Adonica VickersTIME COMPLETED:
04:15 PM
NARRATIVE
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On 7/11/2023, 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 staff Arriyah Rogers. Staff contacted Licensee Adonica Vickers, who arrived a short time later.

All pathways, entrances and exits were clear from obstructions. LPA and staff began the tour at the facility
kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. At 11:42 LPA observed Fire extinguisher in the Kitchen was expired with a service date of 6/10/2022. Tour continued to the living room which has sufficient seating. LPA toured three Residents rooms which were observed to be furnished with required furniture and adequate lighting. At 12:27 LPA observed one of the resident’s rooms windows to be missing a screen. Extra linen supply is kept in the resident’s closets. Additional cleaning supplies and chemicals are kept in the locked garage. Garage has a backup freezer and canned food and sanitary supplies. Medications are kept locked in the hallway closet. At 12:36 LPA observed the laundry room to have laundry detergent that was unlocked. LPA observed sufficient seating under covered patio area in the back of the facility. Backyard gate was self-latching and self-closing. At 1:25 Carbon monoxide was tested and observed to have expired battery. Staff obtained a new battery; smoke alarm detectors installed and operational. At 1:49 LPA reviewed resident’s medication with the MARs. Facility did not have an updated Centrally Stored List for residents. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician’s Report. Frill Drill records were reviewed. Staff files were reviewed for good health. Staff files had First Aid training. Licensee made Facility payment during inspection. Facility Personnel summary report reviewed during inspection.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22,
Division 6.......Continued to next page........
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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: PURPOSEFUL RESIDENTIAL CARE: ERIE PLACE
FACILITY NUMBER: 157208938
VISIT DATE: 07/11/2023
NARRATIVE
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LPA is requesting the following documents be submitted to the Fresno CCL office by 7/25/2023: 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: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/11/2023 04:01 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/11/2023 at 03:23 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: PURPOSEFUL RESIDENTIAL CARE: ERIE PLACE
FACILITY NUMBER: 157208938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 of 1, Carbon monoxide was tested and observed to have expired battery, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Licensee replaced battery of Carbon monoxide detector during inspection visit. POC cleared ******
Type A
Section Cited
CCR
80087(g)
Building 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 above in 1 out of 1, LPA observed laundry detergent and unlocked in the laundry room and accessible to residents which poses an immediate health, safety or personal rights risk to persons in
care.
POC Due Date: 07/12/2023
Plan of Correction
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Licensee removed chemicals and locked them in the garage. POC cleared during visit ****** Licensee will ensure chemicals are locked going forward at all times.
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: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/11/2023 04:01 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/11/2023 at 03:23 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: PURPOSEFUL RESIDENTIAL CARE: ERIE PLACE
FACILITY NUMBER: 157208938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1, LPA observed one of the resident’s room windows to be missing a screen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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Licensee will replace window screen and submit proof to CCLD by due date
Type B
Section Cited
CCR
80075(k)(7)
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the
maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and
includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 residents’
medications were not logged in centrally stored list which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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Licnesee to ensure record of centrally stored prescription medications which is retained for at least one year and includes the following: (A) The name of the client for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E)The prescription number and the name of the issuingpharmacy. (F) Expiration date. (G) Number of refills. Licensee to submit copies of Centrally Stored list for all residents to CCL
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: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/11/2023 04:01 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/11/2023 at 03:45 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: PURPOSEFUL RESIDENTIAL CARE: ERIE PLACE
FACILITY NUMBER: 157208938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the
protection of life and property against fire and panic.

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 of 1. Fire extinguisher was expired
with a service date of 6/10/2022, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Licensee to have fire extinguisher serviced and or buy new and submit pictures as proof of POC to CCLD 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: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
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