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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209073
Report Date: 11/10/2022
Date Signed: 11/21/2022 04:17:43 PM


Document Has Been Signed on 11/21/2022 04:17 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:MARIA LOVING CAREFACILITY NUMBER:
247209073
ADMINISTRATOR:PELAYO, CHRISTINA MFACILITY TYPE:
740
ADDRESS:1115 PAYNE AVENUETELEPHONE:
(209) 733-8136
CITY:GUSTINESTATE: CAZIP CODE:
95322
CAPACITY:6CENSUS: 1DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee- Maria DrumondeTIME COMPLETED:
05:00 PM
NARRATIVE
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On 11/10/2022 at 2:00 p.m. Licensing Program Analyst (LPA) B. Miranda arrived unannounced to the facility for an annual inspection. LPA met with Licensee Maria Drumonde. Licensee stated Christina is no longer the Administrator and Elizabeth Sousa is the Administrator. Elizabeth was contacted and stated Maria can complete the annual inspection. There was no Covid screening upon entrance to the facility.

LPA observed the front door having a double deadbolt and needed to be unlocked from the inside. LPA observed the kitchen clean and clear from clutter. Knives were in a locked closet along with medication. Fire extinguishers were up to date. LPA observed fridge with enough perishable items for 2 days, and enough non-perishable items for 7 days. Some open foods did not have dates, and LPA reminded licensee to date and label open items. Under kitchen sink there were cleaning products accessible to the resident. Smoke alarms were checked and are in working condition.

Bathrooms have grabbing bars and non-slip mats. LPA observed cleaning chemical on the bathroom counter. Water is able to get hot and cold. Temperature of water was not able to be taken at this time. Licensee stated a new water heater was put in on 11/9/2022. LPA informed licensee the hot water temperature should be between 105-120 degrees Fahrenheit.

Facility only has one resident at this time. LPA observed resident's room as clean and free of clutter. The other rooms are clean and free of clutter.

LPA observed back sliding door as being locked and having a stick to also lock the door. Back yard had two sheds, LPA observed sheds are used for storage.

citation will be issued due to fire exits having additional locks not cleared by the Fire Marshall. Citation will also be given for chemicals left accessible to resident.

Report was reviewed with Maria and Elizabeth over the phone, LIC 809 and 809D provided to facility. Exit interview completed.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2022 04:17 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: MARIA LOVING CARE
FACILITY NUMBER: 247209073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
87309 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.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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, due to leaving cleaning supplies/chemicals accessible to resident in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2022
Plan of Correction
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All chemicals will be locked and inaccessible to residents.
Type A
Section Cited
CCR
87705(I)(2)
87705 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:
(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview with administrator & licensee, and record review, the licensee did not comply with the section cited above, the facility did not obtain Fire Department approval to lock backsliding door with stick in sliding area of door or have a double deadbolt lock for the front door. These additional locks pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2022
Plan of Correction
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The double deadbolt can not be used to lock the front door and the stick cannot be used in addition to the lock on the back sliding door.

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: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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