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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247202427
Report Date: 03/28/2023
Date Signed: 04/04/2023 10:25:17 AM


Document Has Been Signed on 04/04/2023 10:25 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: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: 3DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator- Therese RhodesTIME COMPLETED:
04:30 PM
NARRATIVE
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On 3/28/23 at 2:10 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility to conduct a required unannounced annual inspection (AD) Therese was contact and arrived at a later time.

LPA toured the facility inside and out. Outside storage was not inspected at this time due to weather conditions. Fire exits were observed clear and free from obstruction. Fire extinguisher was current in good standing and last serviced 1/16/23. Water temperature was checked in kitchen which reached 107 degrees F and then dropped to 96.5 degrees F. Water temperature was checked in bathroom which read 140.6 degrees F. citation issued under Title 22, Division 6, Chapter 8, 87303 Maintenance and Operation.

Facility currently has 4 bedrooms and 2 bathrooms. Census is currently 3, each resident has their own rooms. LPA observed residents in their rooms sleeping with the exception of one resident watching TV. Rooms were observed to have proper storage, furnishing, and lighting. Master bathroom did not have non-slip mat. Common bathroom had a non-slip mat with mold and toilet with mildew ring.

LPA observed laundry area to have cabinet with bleach & laundry detergent with no lock. Citation issued under Title 22, Division 6 Chapter 8 87309 Storage Space.

LPA observed cleaning supplies and locked and inaccessible to residents. Medication is also locked and inaccessible to residents.

Kitchen was observed to be clean and free from clutter. Knives were locked an inaccessible to residents. Dishwasher machine has odor with mildew and standing water.

Exit interview completed. Copy of this report, LIC809C, LIC809D, and appeal rights were provided to AD.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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 4


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
VISIT DATE: 03/28/2023
NARRATIVE
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Residential Care Facility for the Elderly (RCFE):
  • LIC 308 Designation of Facility Responsibility
  • -as applicable: LIC 309 Administrative Organization
  • -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • -as applicable: LIC 402 Surety Bond
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
  • LIC 9020 Register of Facility Clients/Residents
  • Copy of current Liability Insurance
  • Copy of current Administrator Certificate
  • Alternate contact information including name, telephone number, & email address.
  • Due 4/11/2023
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/04/2023 10:25 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: TERRIE'S TLC SENIOR HOME II
FACILITY NUMBER: 247202427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.LPA observed bleach and laundry detergent not locked and acessible to residents.
POC Due Date: 03/29/2023
Plan of Correction
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All chemicals & cleaning supplies will be locked and inaccessible to residents.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/04/2023 10:25 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: TERRIE'S TLC SENIOR HOME II
FACILITY NUMBER: 247202427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed toilet with mildew rings, non-slip mat with mildew, knives being kept with tools, dishwashing maching with mildew/odor.
POC Due Date: 04/11/2023
Plan of Correction
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AD will have areas cleaned & replace/clean non-slip mat. Verification will be sent to LPA
Type B
Section Cited
CCR
87303(e)(2)
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 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obnservation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed water temperature in common bathroom to read at 140 degrees F.
POC Due Date: 04/11/2023
Plan of Correction
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AD will adjust water heater and sent verification to LPA.
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: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4