160403371-4-11-2024-24-AS-KKAR-D48T3T-20240411142251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 160403371
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:23:02 PM

Document Has Been Signed on 04/11/2024 02:23 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:	MARGIE'S HOME FOR THE AGED		FACILITY NUMBER:	160403371
ADMINISTRATOR:	JAUREZ, MARGARET		FACILITY TYPE:	740
ADDRESS:	313 E. MALONE		TELEPHONE:	(559) 583-6936
CITY:	HANFORD	STATE: CA	ZIP CODE:	93230
CAPACITY:	5	CENSUS: 2	DATE:	04/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Designated Representative Debbie Flores		TIME COMPLETED:	02:30 PM

NARRATIVE

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On 4/11/24, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct an Annual Inspection. LPA was allowed entry by Designated Representative (Designee) Debbie Flores. All two residents were present during the inspection.

The tour started in the common areas into resident's rooms, bathroom, and to the kitchen. The facility was observed to be at a comfortable temperature with no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 04/12/23. LPA observed 7-day supply of non-perishable foods and 2-day supply of perishable foods. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lightning. LPA observed dust on ceiling fan, walls, and air vent. Dust/ debris and stains observed on bedroom carpet. Bathroom observed with securely fastened grab bars. Bathroom observed with no non-skid mat. Bathroom hot water temperature was tested at 115-degree F. LPA observed the bathroom tub to be eroded/ discolored around the drain hole. LPA observed the shower wall edge was broken and exposed. Medications are kept locked in cabinet in the laundry room. First aid kit was observed and contained all required items. The exterior tour was conducted. LPA observed overgrown grass/weeds. Recycling bottles observed all around the gate. Backyard exit gate was locked with a padlock. Exit gate could not open all the way.

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.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22,Division 6.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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 04/11/2024 02:23 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: MARGIE'S HOME FOR THE AGED	FACILITY NUMBER: 160403371
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 areas LPA observed dust on ceiling fans, walls, and air vent. Dust/ debris and stains observed on bedroom carpet. shower wall tile edge was broken and exposed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2024
	Plan of Correction
1 2 3 4	Licensee to complete cleaning and submit pictures to CCLD by due date. Licensee to schedule repair/ replacement in bathroom and send information to CCLD by due date. Once bathroom is repaired Licensee to submit pictures.

Type A

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the licensee did not comply with the section cited above in 1 out of 1; LPA observed the bathroom tub to be eroded/ discolored around the drain hole which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2024
	Plan of Correction
1 2 3 4	Licensee to schedule repair/ replacement in bathroom and send information to CCLD by due date. Once bathroom is repaired Licensee to submit pictures.

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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2024 02:23 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: MARGIE'S HOME FOR THE AGED	FACILITY NUMBER: 160403371
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1; LPA did not observe a non-skid mat in the shower which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2024
	Plan of Correction
1 2 3 4	Licensee to purchase non-skid mat and place in the shower and submit picture or receipt to CCLD by due date

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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2024 02:23 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: MARGIE'S HOME FOR THE AGED	FACILITY NUMBER: 160403371
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

87202(a) Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1; the outside exit gate was locked with a padlock which poses an immediate health, safety or personal rights risk to persons in care. Gate also could not all the way it was getting stuck on the concrete walkway.
	POC Due Date: 04/12/2024
	Plan of Correction
1 2 3 4	Staff removed the padlock during inspection. Licensee to ensure backyard gate is not locked in the future. Licensee will have the gate repair and submit proof when completed.

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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: 04/11/2024

NARRATIVE

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LPA is requesting the following documents be submitted to the Fresno CCL office by 4/18/2024: 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, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Designee. Report signed on-site. Immediate $500 civil penalty assessed a copy of this report, 809D page and appeal rights printed and provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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