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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247208803
Report Date: 10/30/2023
Date Signed: 10/31/2023 09:03:16 PM


Document Has Been Signed on 10/31/2023 09:03 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:WESTSIDE ELDERLY CARE IFACILITY NUMBER:
247208803
ADMINISTRATOR:TOSTADO, MARIA HFACILITY TYPE:
740
ADDRESS:1243 SANTA MARIATELEPHONE:
(209) 826-7120
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:6CENSUS: 5DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Administrator Maria Tostado TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) B. Miranda arrived at the facility to conduct an unannounced Annual Inspection. LPA introduced herself, met with the Administrator (AD) Maria Tostado and explained the reason for the visit.

The facility currently has a license capacity of 6, and there are currently 5 residents. The facility has 4 bedrooms and 3 bathrooms. LPA observed 3 of the 5 residents at the facility interacting with staff in the kitchen. 2 residents were at day program. LPA observed resident bedrooms to be properly furnished.

LPA toured the facility inside and out. LPA observed the facility to be odor free and exits to be clear from obstruction.

LPA observed water temperature to read at 105.4 degrees Fahrenheit in the kitchen. Fire extinguishers were last serviced 10/5/22, and are in good standing condition. AD stated the fire extinguishers will be serviced this month.

LPA observed in the kitchen a few cabinets, water faucet, and dishwasher needing to be cleaned. LPA observed stains in the bathroom toilet bowl needing to be removed. Citation was issued under Title 22, Division 6, Chapter 8.

LPA reviewed a sample of staff files and a sample of resident files.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to AD Maria Tostado.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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 10/31/2023 09:03 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: WESTSIDE ELDERLY CARE I
FACILITY NUMBER: 247208803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) 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 a few cabinets, kitchen faucet, and dishwasher needing to be cleaned. Toilets need to be cleaned from stains.
POC Due Date: 11/06/2023
Plan of Correction
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Pictures will be provided to LPA verifying areas have been cleaned.
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: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2