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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209223
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:31:49 PM

Document Has Been Signed on 05/09/2024 01:31 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:PLEASANT HOME CAREFACILITY NUMBER:
157209223
ADMINISTRATOR/
DIRECTOR:		ASAWADILOKCHAI, YANINEEFACILITY TYPE:
740
ADDRESS:10609 PLEASANT VALLEY DRIVETELEPHONE:
(714) 655-6454
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 1DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Licensee Yaninee AsawadilokchaiTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On 05/09/24, 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 Licensee Yaninee Asawadilokchai. All one resident was present during the inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway


obstructions or fire hazards were observed inside. Sharps observed locked in kitchen pantry. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 37 degrees F and freezer maintained at -7 degree F. Medications were checked and observed kept locked in hall closet. Resident’s MARS was reviewed. Cleaning chemicals observed locked in garage cabinet. Approximately 11:58AM, LPA observed multiple used paint cans, garden tools, and chemical stored in the back of the garage unlock. Resident’s bedrooms and vacant bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are observed with securely fastened grab bars. Hot water temperature was tested 111.8 degrees F. in bathroom and range between 110.8 and 111.7 degrees F in shared bedroom bathroom. Outside of facility toured and observed free of debris with adequate outdoor seatings. Side gate was observed self-closing and self-latching. All one resident’s file reviewed. All one staff file reviewed to have current 1st Aid/CPR certification, fingerprinted cleared and associated. Carbon monoxide and smoke detectors were tested and observed to be operational.

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 submitted to Fresno CCL by: 05/15/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current Administrator Certificate, and current liability insurance. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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 05/09/2024 01:31 PM - It Cannot Be Edited


Created By: Mai Yang On 05/09/2024 at 01:02 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 when LPA observed multiple used paint cans, garden tools, and laundry detergent stored in back of the garage unlock and accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 05/10/2024
Plan of Correction
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Licensee immediately removed the paints, gardening tools and chemical and stored in the lock garage cabinet. POC clear 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: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 01:31 PM - It Cannot Be Edited


Created By: Mai Yang On 05/09/2024 at 01:16 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: PLEASANT HOME CARE
FACILITY NUMBER: 157209223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
87303 (e)(5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 did not observed a non-skid mat in the resident’s bathtub this poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Licensee shall ensure a non-skid mat or strip is in the resident’s bathtub. Proof of non-skid mat or strip is in the resident’s bathtub shall be submitted to the department by 05/15/24.
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: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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