157209103-9-26-2022-24-AS-KKAR-CJMSU5-20220926141035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157209103
Report Date: 09/26/2022
Date Signed: 09/26/2022 02:11:29 PM

Document Has Been Signed on 09/26/2022 02:11 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:	AAA RESIDENTIAL ELDERLY RETREAT		FACILITY NUMBER:	157209103
ADMINISTRATOR:	BELL, ALEXIS E		FACILITY TYPE:	740
ADDRESS:	4313 MONITOR STREET		TELEPHONE:	(661) 213-6798
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93307
CAPACITY:	6	CENSUS: 5	DATE:	09/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Alexis Bell, Administrator		TIME COMPLETED:	02:10 PM

NARRATIVE

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On 9/26/22, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and was allowed entry by Staff Gwen Bonner. Staff contacted Administrator who would be arriving shortly

Facility staff were observed without mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Social distancing and cough etiquette postings observed in facility. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. 30-day PPE supplies were observed.

Sharp items were locked in kitchen cabinet. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Medications observed locked in hallway closet. At 11:45 AM LPA reviewed R1’s Centrally Stored Medication list, MARS and medication and observed missing pills. Fire extinguisher service date of 1/14/2022 in dining area. LPA toured bathrooms. Hand washing signs and trash bins were observed with no lids. Securely fastened grab bars observed in bathroom. Resident rooms toured and observed to be adequately furnished and lit. The exterior tour was conducted. Staff records were reviewed for good health and infection control training. Residents’ records reviewed to have updated emergency contact.

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 10/3/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator

Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and
Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with staff. Report signed on-site and printed copy provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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 09/26/2022 02:11 PM - It Cannot Be Edited

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: AAA RESIDENTIAL ELDERLY RETREAT	FACILITY NUMBER: 157209103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(5)

87465(a)(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 medications that were reviewed had missing pills and interview with the administrator could not proof and or did not have information for the missing medication which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2022
	Plan of Correction
1 2 3 4	The Licensee agrees to maintain a centrally stored log with start dates on log and on medications to ensure all clients are receiving their medications. The Licensee will assign designated individuals to administrator medication instead of all staff. The Licensee agrees to review all medication given and logged after administrating to confirm accuracy and provide documents as proof of correction.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

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