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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209073
Report Date: 11/01/2023
Date Signed: 11/02/2023 09:32:37 PM

Document Has Been Signed on 11/02/2023 09:32 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:
11/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Maria DrumondeTIME COMPLETED:
04:15 PM
NARRATIVE
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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 Licensee Maria Drumonde and explained the reason for the visit.

The facility currently has a license capacity of 6, currently there is 1 resident. The facility has 4 bedrooms and 2 bathrooms. LPA observed the resident sitting in the Living Room reading the newspaper.

LPA observed the facility to be clean, free from clutter, and odor free. LPA observed fire clearance exits located on the side of the facility to be obstructed with locks needing key, sliding door also has stick obstructing door.

LPA observed kitchen to be clean. LPA observed 2 days worth of perishable food items, and 7 days worth of non-perishable food items. Smoke detectors and carbon monoxide readers were tested and are in working condition. First aid kit was missing scissors and thermometer.

LPA observed residents room which is properly furnished. Residents room currently has items being stored in closet that belong to Licensee and not the resident.

LPA tested the water temperature in the common bathroom which read at 138.4 degrees Fahrenheit.

Resident's file and Licensee's files were reviewed and need to be updated.

Citations were issued on LIC809D

Exit interview was conducted and a copy of this report LIC809, LIC809, and appeal rights were provided to Licensee.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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 11/02/2023 09:32 PM - It Cannot Be Edited


Created By: Brianna Miranda On 11/01/2023 at 03:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MARIA LOVING CARE
FACILITY NUMBER: 247209073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
(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 & interview 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 backyard gates to be inaccessible due to lock requiring a key. Both side gates leading to the front of the house are locked and inaccessible. Back sliding door has stick blocking the door from being opened. Exit through the garage is obstructed and has a narrow pathway. Residents with a walker or wheelchair cannot use exit.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee needs to provide current fire clearance sketch indicating the fire clearance exits. All obstructions need to be removed from fire clearance exits. Verification will be provided to LPA.
Type A
Section Cited
CCR
87465(a)(6)
6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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 in which poses an immediate health, safety or personal rights risk to persons in care. Licensee stated there is no written record of medication being dispensed to the resident.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee will complete Centrally Stored log for all medication being dispensed to the resident in care. Verification 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
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/02/2023 09:32 PM - It Cannot Be Edited


Created By: Brianna Miranda On 11/01/2023 at 03:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MARIA LOVING CARE
FACILITY NUMBER: 247209073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
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 tested the water in the common bathroom of the facility and observed the water temperature to be at 138.4 degrees Fahrenheit.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee will have water temperature adjusted and provide proof to LPA that water temperature is between 105-120 degrees Fahrenheit.
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 Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/02/2023 09:32 PM - It Cannot Be Edited


Created By: Brianna Miranda On 11/01/2023 at 03:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MARIA LOVING CARE
FACILITY NUMBER: 247209073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)(1-4)
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
(1) The specific symptoms which indicate the need for the use of the medication.
(2) The exact dosage.
(3) The minimum number of hours between doses.
(4) The maximum number of doses allowed in each 24-hour period.


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 observed resident in care is taking vitamins with no orders in the resident's file.
POC Due Date: 11/15/2023
Plan of Correction
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Licensee will obtain proper documentation from the resident's physician regarding any PRNs. Verification will be provided to LPA.
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 Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
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