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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209299
Report Date: 01/31/2024
Date Signed: 01/31/2024 01:30:15 PM


Document Has Been Signed on 01/31/2024 01:30 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:LERWICK HOME CAREFACILITY NUMBER:
157209299
ADMINISTRATOR:TELMO, SOCORRO ANNFACILITY TYPE:
740
ADDRESS:10213 LERWICK AVENUETELEPHONE:
(661) 665-2874
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator Socorro Ann Telmo TIME COMPLETED:
01:30 PM
NARRATIVE
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On 1/31/24, 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 Socorro Ann Telmo was called and arrived shortly and conduct tour with LPA. All five residents were present during the inspection.

The tour started in the kitchen into the common areas to the residents’ rooms. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Kitchen knives were observed unlock in kitchen drawer. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 37 degrees F and freezer maintained at 0 degree F. Fire extinguisher was observed with a service date of: 03/24/23. Medications were checked and observed kept locked in kitchen cabinet. Residents’ MARS was reviewed.

Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested 110.8 degrees F. in bathroom 1 and 115.3 degrees F. in bathroom 2. Cleaning chemicals was observed stored and locked under kitchen sink and in the garage. Outside of facility toured. Adequately seating was observed outside for resident. Side gate was self-closing and self-latching. All resident and staff files reviewed to have all the required documents. 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: 02/06/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, control of property, current Administrator certificate, and current liability insurance. A copy of this report and appeal rights was provided to Administrator, 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: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 01/31/2024 01:30 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: LERWICK HOME CARE
FACILITY NUMBER: 157209299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 (f)(1) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 at approximately 12:05 PM, multiple kitchen knives in kitchen drawer unlock and accessible to residents poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 02/01/2024
Plan of Correction
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Administrator immediately removed all the knives and locked under kitchen sink. 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 MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/31/2024 01:30 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: LERWICK HOME CARE
FACILITY NUMBER: 157209299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
87465(d)(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

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 reviewed R1’s MARs and medications and observed that R1’s medication Senna Plus Tab 50-8.6 was administered up to current date however there were no documentation of the medication being administered to the residents which poses a potential health, safety or personal rights risk to person in care.
POC Due Date: 02/06/2024
Plan of Correction
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Administrator shall have staff retrained on administering medication to ensure that all medication being administered to the resident is being logged. A copy of the training shall be submitted to the Fresno CCL office by POC due date 02/06/24.
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: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3