<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247204136
Report Date: 12/18/2023
Date Signed: 12/18/2023 09:27:56 PM


Document Has Been Signed on 12/18/2023 09:27 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 HOMEFACILITY NUMBER:
247204136
ADMINISTRATOR:RHODES, THERESEFACILITY TYPE:
740
ADDRESS:1231 E. DONNA AVETELEPHONE:
(209) 384-3056
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:6CENSUS: 2DATE:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Administrator Therese RhodesTIME COMPLETED:
03:00 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 12/18/23 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct an annual inspection. Administrator (AD) Therese Rhodes was contacted and informed of the reason for the visit.

Facility is licensed for a capacity of 6, facility current has a census of 2. LPA observed both residents in the common area. Upon entry to the facility LPA observed the facility to be clean, clear from clutter, and odor free.

LPA observed resident's bedrooms which appear to be properly furnished and have adequate storage space.
LPA tested water faucet in the kitchen, water temperature read at 115.5 degrees F.
LPA observed fire extinguisher which was last serviced in March 2023 and in good standing. LPA observed smoke detectors which appeared to be in working condition.

LPA observe medication, chemicals, and sharps to be locked and inaccessible to residents.


A sample of resident files were reviewed and a sample of staff files were reviewed.

LPA observed master bedroom exit door to be obstructed with a bed. Side gate to exit the backyard had a blue bin and LPA had difficulty opening the side gate.


LPA conducted an exit interview and a copy of this report LIC809, LIC809D, and appeal rights were provided to Therese Rhodes.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
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 2


Document Has Been Signed on 12/18/2023 09:27 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
FACILITY NUMBER: 247204136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & record review, 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 the exit door in the master bedroom to be obsertucted with a medical bed. Siide gate leading out of the back yard has the recycle bin in the pathway and LPA was unable to open the gate completely.
POC Due Date: 12/19/2023
Plan of Correction
1
2
3
4
Administrator will have the bed removed and verification will be sent to LPA.
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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2