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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167204056
Report Date: 01/22/2025
Date Signed: 01/22/2025 01:35:30 PM

Document Has Been Signed on 01/22/2025 01:35 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:LEMOORE ADULT DAYFACILITY NUMBER:
167204056
ADMINISTRATOR/
DIRECTOR:		WARTSON, BOBBIEFACILITY TYPE:
775
ADDRESS:1075 BLAKE STREETTELEPHONE:
(559) 924-4419
CITY:LEMOORESTATE: CAZIP CODE:
93245
CAPACITY: 15CENSUS: 6DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Program Director, Pam ChinTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 1/22/25 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Program Director, Pam Chin. LPA introduced self, explained reason for visit and was permitted entry into the facility.

LPA completed a health and safety check on clients in care. LPA toured the facility inside and out. Facility is 1 large room with 1 restroom and kitchen. Doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present at time of visit. Fire extinguisher last serviced 11/7/24. Last fire drill conducted on 11/20/24. LPA observed sufficient seating in outdoor area.

The following issues were observed during todays visit: Bathroom tile broken/missing and in need of repair. Debris observed behind shed in need of removal. Chemicals and sharps observed in kitchen area and in shed unlocked and accessible to clients in care. Food in refrigerator/freezer not properly stored/dated. Back yard walkway of facility observed with debris in need of removal. Water temperature in bathroom measured at 102.8 degrees F.

LPA requested the following documents to be submitted to CCL by 1/31/2025: current copy of Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Deficiencies cited per Title 22. Exit interview completed with Program Director, Pam. A copy of this report, deficiencies and TV’s were provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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 01/22/2025 01:35 PM - It Cannot Be Edited


Created By: Mary Garza On 01/22/2025 at 01:00 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: LEMOORE ADULT DAY
FACILITY NUMBER: 167204056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that bathroom tile broken/missing and in need of repair. Debris observed behind shed in need of removal. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Program Director stated they will get in contact with the gardener for the debris behind the shed to be removed. Handyman will be contacted to fix the tile. Tile has already been purchased. Pictures will be taken and sent to CCL by POC date as proof of correction.
Type B
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, 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 LPA observation, the licensee did not comply with the section cited above in chemicals and sharps observed in kitchen area and in shed unlocked and accessible to clients in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Program Director stated they will purchase a locked container for the sharps and door will remain closed and locked at all times. Receipt will be provided to CCL as proof of correction.
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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/22/2025 01:35 PM - It Cannot Be Edited


Created By: Mary Garza On 01/22/2025 at 01:00 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: LEMOORE ADULT DAY
FACILITY NUMBER: 167204056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(c)
Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in back yard sidewalk of facility observed with debris in need of removal. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Program Director stated they will remove all debris from the walkway. A picture will be sent to CCL by POC date as proof of correction.
Type B
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in water temperature in bathroom measured at 102.8 degrees F. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Program Director stated they will get with KCA to adjust temperature of water heater. Program will complete a water log for 2 weeks and provide to CCL as proof of correction.
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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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