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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247208959
Report Date: 07/20/2023
Date Signed: 07/21/2023 05:49:46 PM


Document Has Been Signed on 07/21/2023 05:49 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:AT HAVEN HOMEFACILITY NUMBER:
247208959
ADMINISTRATOR:BURNS, JASMINFACILITY TYPE:
740
ADDRESS:644 DARTMOUTH COURTTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:6CENSUS: 5DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Maria Knight - ManagerTIME COMPLETED:
04:00 PM
NARRATIVE
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On 7/6/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Required Annual Inspection. LPA met with Manager Maria Knight and announced the purpose of the inspection.

LPA toured the facility inside and outside. Smoke-detectors and carbon-monoxide detectors were present and operational. Facility was clean and odor free. LPA observed sufficient amount of perishable and non-perishable foodstuffs. Common areas were clean, adequately furnished, and adequately lit. Resident bedrooms were clean and had required minimum furnishings. Resident bathrooms were clean, odor free, and water temperature was within required temperature range. Sharp items were secured in a locked drawer. A locked cabinet was observed to store resident medications. LPA reviewed facility plan of operations and emergency disaster plan. LPA reviewed a sample of resident files. The following deficiencies were observed during the inspection: three exterior doors were locked due to dementia residents being a risk to exit the facility, one out of five resident files did not include an admission agreement, one out of five resident files did not include a physician's report, staff were utilizing full length bed rails for a resident who was not on hospice care, and staff were not documenting doses of a PRN on one out of five residents' medication administration records(MAR's). See attached LIC 809D's for five type B citations issued in accordance with Title 22, California Code of Regulations.

CCLD requested the following documents to update the facility file: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan, LIC 9020 Regirtser of Facility Residents, and a copy of current Administrator’s Certificate.
Exit interview conducted. A copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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


Document Has Been Signed on 07/21/2023 05:49 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: AT HAVEN HOME
FACILITY NUMBER: 247208959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of five resident files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2023
Plan of Correction
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LPA will collaborate with Administrator to develop an appropriate plan of correction.
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of five resident files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2023
Plan of Correction
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LPA will collaborate with Administrator to develop an appropriate plan of 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 ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 07/21/2023 05:49 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: AT HAVEN HOME
FACILITY NUMBER: 247208959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of five medication adminidtration records, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2023
Plan of Correction
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LPA will collaborate with Administrator to develop an appropriate plan of correction.
Type B
Section Cited
CCR
87705(l)(1)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.

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 in three out of seven exterior doors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2023
Plan of Correction
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LPA will collaborate with Administrator to develop an appropriate plan of 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 ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/21/2023 05:49 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: AT HAVEN HOME
FACILITY NUMBER: 247208959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
87608 Postural Supports:(a)...Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above for 2 out of 5 residents which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2023
Plan of Correction
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LPA will collaborate with Administrator to develop an appropriate plan of correction.
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) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4