167206337-4-4-2024-24-AS-MGAA-D3ZNEX-20240404102438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 167206337
Report Date: 03/27/2024
Date Signed: 04/04/2024 10:24:54 AM

Document Has Been Signed on 04/04/2024 10:24 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:	EASY LIVING SENIOR HOME		FACILITY NUMBER:	167206337
ADMINISTRATOR:	DAULTON, RONNETTE		FACILITY TYPE:	740
ADDRESS:	419 CHAMPION		TELEPHONE:	(559) 925-1413
CITY:	LEMOORE	STATE: CA	ZIP CODE:	93245
CAPACITY:	6	CENSUS: 6	DATE:	03/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	House Manager, Delores Contreras		TIME COMPLETED:	03:51 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03272024 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by House Manager, Delores Contreras. Licensee, Ronette Daulton was contacted. LPA introduced self, explained reason for visit and was permitted entry into the facility. Licensee gave permission for House Manager, Delores to complete visit with LPA. LPA completed a health and safety check on residents in care. 6 of 6 residents present and observed in common area at time of visit. LPA toured the facility inside and out. There were 3 resident on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Fire extinguisher purchased in 03/2023 and fully charged. Water temperature measured 120 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in laundry room cabinets. Sharps were located in locked cabinets/closets. LPA observed sufficient seating under covered patio areas. LPA requested the following documents to be submitted to CCL by 4/5/2024: current copy of Administrator’s Certificate, 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. CONT...

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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 04/04/2024 10:24 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: EASY LIVING SENIOR HOME	FACILITY NUMBER: 167206337
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that the facility license states facility if approved to have 2 hospice residents. Facility currently has 3 residents on hospice without an approved exception/wavier. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2024
	Plan of Correction
1 2 3 4	Administrator/Licensee is to provide an exception request to CCL by 3/28/24. This is to include all required documentation per regulation.

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) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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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: EASY LIVING SENIOR HOME	FACILITY NUMBER: 167206337
	VISIT DATE: 03/27/2024

NARRATIVE

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CONT...

The following issues were observed during visit: License is approved for 2 hospice residents. Facility currently has 3 without an approved exception/wavier. Smoke detectors and carbon monoxide detectors were present and non-operational at time of arrival. This was corrected during visit. Fire drills not being completed. Chemicals and medications observed in residents rooms unlocked and accessible. Deficiencies cited on LIC 809D per Title 22 regulation.

Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with House Manager, Delores.

A copy of this report, deficiencies, TV's and appeal rights provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 04/04/2024 10:24 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: EASY LIVING SENIOR HOME	FACILITY NUMBER: 167206337
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(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:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that 5 of 6 resident rooms and 1 of 2 bathrooms were observed with chemicals/medications accessible to clients in care. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Per House Manager, locks will be placed on the areas with the chemicals/medications. Proof will be provided to CCL in the form of a picture/video by POC 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) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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