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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247202427
Report Date: 03/26/2024
Date Signed: 03/26/2024 04:44:13 PM


Document Has Been Signed on 03/26/2024 04:44 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:TERRIE'S TLC SENIOR HOME IIFACILITY NUMBER:
247202427
ADMINISTRATOR:RHODES, THERESE ANNEFACILITY TYPE:
740
ADDRESS:1317 E BROOKDALE DR.TELEPHONE:
(209) 726-0548
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:6CENSUS: 4DATE:
03/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Licensee Therese RhodesTIME COMPLETED:
05:00 PM
NARRATIVE
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On 3/26/24, Licensing Program Analyst (LPA) B. Miranda conducted a required unannounced Annual Inspection visit. LPA introduced herself, stated purpose of visit, and was allowed entrance by Staff. Licensee Therese Rhodes was contacted and arrived shortly after.

LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPA observed facility to be clean, clutter free, and odor free. All fire exit routes were free and clear of obstructions. Medications are stored in a locked cabinet in the kitchen. LPA observed Centrally Stored Medication log to be completed incorrectly. Citation issued per California Code of Regulations Title 22. Toxins, cleaning supplies, knives and sharp objects are secured and inaccessible to residents.

Facility has 4 bedrooms and 2 bathrooms. Residents do not share bedrooms. Fire extinguisher was last serviced 1/16/23 and will be serviced soon per Licensee. Fire extinguisher still has charge. Smoke alarm was tested and is in working condition. Water temperature was checked in the resident's common bathroom and read at 132.3 degree Fahrenheit. Citation issued per California Code of Regulations Title 22.


LPA observed a sample of resident files which are complete and up to date. LPA observed a sample of staff files, Licensee will provide a copy of current training by 4/1/24.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Licensee.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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 03/26/2024 04:44 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: TERRIE'S TLC SENIOR HOME II
FACILITY NUMBER: 247202427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2024
Section Cited
CCR
87465(h)(6)(A-F)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(A) The name of the resident for whom prescribed.(B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy.
(F) Instructions, if any, regarding control and custody of the medication.
This requirement is not met as evidenced by:


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Licensee will correct and update centrally stored log for the resident's medications.
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This requirement is not met as evidenced by: Based on observations, interviews, & record review(s), the licensee failed to maintain the centrally stored log. R1's centrally stored log was not properly maintained.
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Type A
03/27/2024
Section Cited
CCR87303(e)(2)

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87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
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Licensee will adjust the water temperature and provide verification to LPA.
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This requirement is not met as evidenced by: Based on observations, the licensee failed to keep the water temperature between 105 & 120 degrees F.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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