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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 160403371
Report Date: 04/12/2023
Date Signed: 04/17/2023 09:46:17 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/17/2023 09:46 AM - 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:MARGIE'S HOME FOR THE AGEDFACILITY NUMBER:
160403371
ADMINISTRATOR:JAUREZ, MARGARETFACILITY TYPE:
740
ADDRESS:313 E. MALONETELEPHONE:
(559) 583-6936
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY:5CENSUS: 2DATE:
04/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Designated Representative Debbie FloresTIME COMPLETED:
02:30 PM
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On 4/12/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA was greeted by staff Mary Prescott. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. Designated Representative (Designee) Debbie Flores was called and arrived shortly. All two residents were present during the inspection. LPA conduct interviews with staff and residents.

The tour started in the common areas into resident's rooms, bathroom, and to the kitchen. LPA observed COVID-19 related signs. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 04/14/23.

Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lightning. LPA observed one shared residents’ bed to be at least 6 feet apart. All bathrooms are observed with securely fastened grab bars. Bathroom observed with no non-skid mat. Bathrooms hot water temperature was tested at 115-degree F. in bathroom. LPA observed trash can with lid and hand washing signs. Medications are kept locked in cabinet in the laundry room. Residents’ MARs were reviewed. First aid kit was observed and contained all required items. An adequate supply of perishable and non-perishable food was observed to be properly stored. Knives were observed in kitchen drawer unlock. Cleaning chemicals observed in cabinet unlocked in staff area. The exterior tour was conducted. Gardening tools were observed unlocked stored against outside wall. Side gate was self-closing and self-latching.

All of the residents’ file reviewed to have update emergency contacts, Admission agreement, and physician report. All of the staff files were also reviewed. Staff files were observed to have current First Aid/CPR. 3 out of 4 staff files observed to have Criminal Record Statement and TB results. Carbon monoxide and smoke detectors were tested and observed to be operational.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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


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: MARGIE'S HOME FOR THE AGED
FACILITY NUMBER: 160403371
VISIT DATE: 04/12/2023
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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: 4/24/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, facility sketch, current liability insurance, and current Administrator certificate. A copy of this report was provided to the Designated Representative via email whose signature on this form confirms receipt of these report. Signed report on file.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/17/2023 09:46 AM - 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: MARGIE'S HOME FOR THE AGED
FACILITY NUMBER: 160403371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2023
Section Cited

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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:
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Staff immediately relocate the knives into a locked cabinet. Licensee shall lock and secure cleaning chemicals and gardening tools by POC due date.
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Based on observation, the licensee did not comply with the section cited above when LPA and designee observed at 11:49 AM multiple knives stored in unlock kitchen drawer and cleaning cabinet unlock. Multiple gardening tools observed outside in the back stored against the facility wall. Two ambulatory residents where present during observation. Knives, chemicals, and gardening tools observed unlock and accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
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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: 04/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2023
LIC809 (FAS) - (06/04)
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