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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167208806
Report Date: 05/09/2024
Date Signed: 05/10/2024 08:47:04 AM


Document Has Been Signed on 05/10/2024 08:47 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:CHESTER CARE HOME 2FACILITY NUMBER:
167208806
ADMINISTRATOR:CHESTER, FLORAYFACILITY TYPE:
735
ADDRESS:1558 PEACHWOOD STREETTELEPHONE:
(559) 362-5674
CITY:LEMOORESTATE: CAZIP CODE:
93245
CAPACITY:6CENSUS: 5DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Licensee, Floray ChesterTIME COMPLETED:
03:35 PM
NARRATIVE
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On 5/9/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Licensee, Floray Chester. LPA introduced self, explained reason for visit and was permitted entry into the facility.

Residents at day program during time of visit. LPA toured the facility inside and out. Pathways and doors were clear and free from obstruction inside facility. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present. Fire extinguisher last serviced 5/16/23. Last fire drill on 2/2/24. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps and medications were located in locked closets/cabinets. LPA observed sufficient seating under covered area.

During visit the following issues were observed: Water hose spread across the yard causing a potential tripping hazard. 1 of 3 dishes observed with chipping/cracking. Deck observed without hand rails/lighting causing a potential tripping hazard. Hygiene products including mouthwash observed in restrooms under sink accessible to residents in care.

LPA requested the following documents to be submitted to CCL by 5/17/23: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Deficiencies cited and TA's provided during the inspection. Exit interview completed with Licensee, Floray Chester. A copy of this report, deficiencies, TA's and appeal rights provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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 2


Document Has Been Signed on 05/10/2024 08:47 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: CHESTER CARE HOME 2
FACILITY NUMBER: 167208806

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(b)
Building and Grounds
(b) Stairways, inclines, ramps, open porches, and areas of potential hazard to clients whose balance or eyesight is poor shall not be used by clients unless such areas are well lighted and equipped with sturdy hand railings.

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 decking area did not have hand railings or lighting which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Property is being leased. Decking is provided by property owner. Licensee to speak with owner regarding handrailing/lighting. POC to be provided in writing to CCL by POC date.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 that hygiene items including mouthwash was observed in bathrooms accessible to residents in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee stated magnetic locks will be installed and items will be locked. Residents will be provided a key to access their items.
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) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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