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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209268
Report Date: 01/17/2024
Date Signed: 01/17/2024 02:24:57 PM


Document Has Been Signed on 01/17/2024 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:PRECIOUS LIFE RESIDENCES, LLCFACILITY NUMBER:
157209268
ADMINISTRATOR:CRISOSTOMO, PETROFACILITY TYPE:
740
ADDRESS:10414 BICHESTER COURTTELEPHONE:
(661) 472-9253
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 6DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Petro Crisostomo and caregiver Nicky Denzel BarrogaTIME COMPLETED:
02:30 PM
NARRATIVE
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On 01/17/24, 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 Administrator. LPA met with caregiver Brenda Munoz-Perez. Licensee (L1) Susan Blanza was called and stated unable to attend meeting. Administrator Petro Crisostomo arrived shortly and toured facility with LPA. All 5 residents were present upon 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. Fire extinguisher was observed with purchased date of 1/17/24. An adequate supply of perishable and non-perishable food was observed. Medications were checked and observed kept locked in dining room cabinet. MARS was reviewed. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured. All bathrooms were observed operating and functioning during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested between range 109.6 and 109.7 degrees in bedroom 4 bathroom. Hot water temperature was tested at 108.3 in bathroom. Outside of facility toured. Side gate was observed self-closing and free of debris. Adequate outdoor seating available for residents.

All residents’ file reviewed to have Admission agreement, physician report and emergency information. LPA reviewed four staff files to have all required documents, fingerprinted cleared and associated to the facility. Carbon monoxide and smoke detectors were tested and observed to be operational.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 01/26/24. Forms requested: Lic 308, Lic 500, Lic 610E, and current liability insurance. LPA received a copy of current Administrator certificate and facility sketch. A copy of this report and appeal rights was provided to designee whose signature on this form confirms receipt of these report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 01/17/2024 02:24 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...

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 and Administrator observed at approximately 11:18 AM in bedroom 1, Resident 1 (R1)’s whose able to store own medication, all R1's medications stored on top and in a rolling night stand unlock. At approximately 11:22 AM, LPA and Administrator observed in bedroom 4 bathroom, Risamine ointment, Dayquil 12 oz, and Hydrocortisone cream 1% stored under bathroom sink unlock. LPA and Administrator was informed by staff that Resident 3 (R3)’s Triamclinolone 1% cream was stored under bathroom sink unlock. Medications were observed unlock and accessible to residents poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 01/18/2024
Plan of Correction
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Administrator and caregiver removed immediately the medications from R2’s bathroom and R3’s medication into lock cabinet. Licensee shall submit POC of how and where R1’s medication shall be locked and inaccessible to other residents in the facility but accessible to R1 by due date or 1/18/24. R1’s medication shall be locked and inaccessible to residents in care shall be submitted to CCL by POC due date of 1/018/24.
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 MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 01/17/2024 02:24 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN
medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, LPA and Administrator reviewed residents’ MARs and observed five out of six residents’ medications that were dispense were not documented for three occasions. Resident 4 (R4)’s PRN medication Miralax documented administered by staff for three days after medications had ran out and last dispensed on 01/14/24. MAR not documented correctly by staff possess a potential health and safety risk for the person in care.
POC Due Date: 01/26/2024
Plan of Correction
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Licensee shall submit a written Plan of Correction (POC) Licensee agrees to retrained staff on proper administering medication and documentation. Licensee will submit documentation of training topics and staff attendance roster to CCL by POC due date 1/26/24.
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 MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4