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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
247206253
Report Date:
07/23/2024
Date Signed:
07/23/2024 07:24:18 PM
Document Has Been Signed on
07/23/2024 07:24 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:
INTEGRATED HEALTH CARE LLC
FACILITY NUMBER:
247206253
ADMINISTRATOR:
KRYSTYL SHEEN IBANEZ
FACILITY TYPE:
740
ADDRESS:
1503 ESPLANADE DRIVE
TELEPHONE:
(209) 749-1009
CITY:
MERCED
STATE:
CA
ZIP CODE:
95348
CAPACITY:
6
CENSUS:
5
DATE:
07/23/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:10 PM
MET WITH:
Administrator Krystyl Ibanez
TIME COMPLETED:
08:00 PM
NARRATIVE
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On 7/23/24, Licensing Program Analysts (LPAs) B. Miranda & M.
Vega arrived at the facility unannounced to conduct a required unannounced Annual Inspection visit. LPAs introduced themselves, stated purpose of visit, and was allowed entrance by staff. Administrator Krystyl Ibanez was contacted and arrived later.
Upon arrival LPAs observed S1 who was not properly associated to the facility to be working with residents, Administrator stated S1 has been rehired as of 7/6/24.
LPAs toured the facility inside and out including to include kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPAs observed one outside exit from the back had items on the ground and a plant covers half of the walkway. R1's exit from the room is obstructed by a chair and fan, and screen door needs to be fixed. Medications are stored in a locked cabinet in the kitchen. LPAs observed hygiene products to be accessible to residents in care, R2's physician report states the products should not be accessible to resident. LPAs observed knives and sharp objects to be secured. LPAs observed expired sandwich meat and food items not properly labeled in the refrigerator. LPAs observed dishwasher to have an odor and mildew buildup. Staff stated dishwasher is not used except to air dry clean dishes. LPA also observed dishwasher pods unlocked and accessible to residents.
Facility has a capacity of 6 with a current census of 5. Smoke alarms are in working condition. Carbon monoxide detector was tested and in working condition. Water temperature was checked in the kitchen and read at 114.8 degrees Fahrenheit.
LPA was not able to review current infection control plan and staff files were not current. LPAs did not observe S1's file at the facility.
Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Staff Elisa Cervera. Administrator allowed staff to sign the reports.
SUPERVISOR'S NAME:
Brenda Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Brianna Miranda
TELEPHONE:
559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE:
07/23/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/23/2024
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
6
Document Has Been Signed on
07/23/2024 07:24 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:
INTEGRATED HEALTH CARE LLC
FACILITY NUMBER:
247206253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/23/2024
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
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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 one fire exit to have items on the ground of the pathway to the exit and a plant blocking the walkway.
POC Due Date:
07/24/2024
Plan of Correction
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3
4
Items will be removed and pictures will be provided to LPA
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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3
4
Based on observation, interview, 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 dishwasher pods in kitchen drawer accessible to residents. R2's physician report indicates they should not have hygiene products accessible to resident. Hygiene products were accessible to residents in common bathroom.
POC Due Date:
07/24/2024
Plan of Correction
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4
Items will be removed and verification will be sent 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 Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Brianna Miranda
TELEPHONE:
559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE:
07/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/23/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
07/23/2024 07:24 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:
INTEGRATED HEALTH CARE LLC
FACILITY NUMBER:
247206253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, & record review, 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 was not able to review infection control plan due to not being at the facility.
POC Due Date:
08/02/2024
Plan of Correction
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Administrator will provide updated infection control plan.
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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4
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. LPAs observed dishwasher having mildew buildup and odor. Drinking water container needs to be cleaned/replaced.
POC Due Date:
08/02/2024
Plan of Correction
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2
3
4
Pictures will be sent to verify correction.
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 Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Brianna Miranda
TELEPHONE:
559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE:
07/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/23/2024
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
07/23/2024 07:24 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:
INTEGRATED HEALTH CARE LLC
FACILITY NUMBER:
247206253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, & record review, 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 was not able to review completed staff files while at the facility.
POC Due Date:
08/02/2024
Plan of Correction
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Plan will be created so LPA has access to completed staff files.
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, 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 did not observe current training for staff.
POC Due Date:
08/02/2024
Plan of Correction
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4
Administrator will conduct staff training for all staff members.
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 Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Brianna Miranda
TELEPHONE:
559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE:
07/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/23/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
07/23/2024 07:24 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:
INTEGRATED HEALTH CARE LLC
FACILITY NUMBER:
247206253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, 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 mildew and odor coming from dishwasher which is used to air dry clean according to staff.
POC Due Date:
08/02/2024
Plan of Correction
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2
3
4
Dishwasher will be cleaned and verification will be provided to LPA.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, 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. Administrator stated medication is put in a container to give at a later time within 24 hours.
POC Due Date:
08/02/2024
Plan of Correction
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2
3
4
Administrator will provide plan of correction 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 Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Brianna Miranda
TELEPHONE:
559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE:
07/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/23/2024
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
07/23/2024 07:24 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:
INTEGRATED HEALTH CARE LLC
FACILITY NUMBER:
247206253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, 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 S1 to be working in the facility without being properly associated to the facility. Administrator stated S1 has been working at the facility since 7/6/24.
POC Due Date:
07/24/2024
Plan of Correction
1
2
3
4
Administrator will provide LPA with a statement explaining S1 will not return to the facility until properly associated.
Type A
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review the licensee did not comply with the regulation listed above. Facility has residents who have dementia and can be disoriented at times. LPA observed the audio alarms on the exits to be off or not in working order.
POC Due Date:
07/24/2024
Plan of Correction
1
2
3
4
Verification and plan regarding audio alarms will be provided 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 Chan
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Brianna Miranda
TELEPHONE:
559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE:
07/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/23/2024
LIC809
(FAS) - (06/04)
Page:
6
of
6