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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209199
Report Date: 02/20/2024
Date Signed: 02/26/2024 01:13:56 PM


Document Has Been Signed on 02/26/2024 01:13 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 HOME IIFACILITY NUMBER:
247209199
ADMINISTRATOR:BURNS, JASMINFACILITY TYPE:
740
ADDRESS:3763 N LAKE ROADTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:13CENSUS: 12DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Jasmin BurnsTIME COMPLETED:
03:30 PM
NARRATIVE
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On 2/20/24, Licensing Program Analyst (LPA) B. Miranda conducted a required unannounced Annual Inspection visit. LPA introduced self, stated purpose of visit, and allowed entrance by staff. Administrator Jasmin Burns was contacted and arrived shortly after.

LPA observed the facility to be clutter free, exits to be free from obstruction, and odor free. LPA observed 4 residents sitting at the kitchen table and 2 residents sitting in the living room area.

LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. All fire exit routes were free and clear of obstructions. Majority of medications are stored in a locked cart the office, LPA did observe some medication unlocked and accessible to residents. Majority of toxins, cleaning supplies, knives and sharp objects are secured, LPA did observe some degrease solution to be unlocked and accessible to residents. In an unlocked drawer LPA observed a hammer and screw driver.

Carbon monoxide detector was tested and in working condition. Water temperature was checked in various facets and read at 96.7 degree Fahrenheit. LPA observed various toilets to have a mildew/mold ring and one resident's shower to have mold.

LPA reviewed a sample of employee records which were missing current training verification. Three staff members are not properly associated with the facility. LPA reviewed resident files which were not current or up to date. S1 is missing current physician report and PRN on file.


Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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 5


Document Has Been Signed on 02/26/2024 01:13 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 II
FACILITY NUMBER: 247209199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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 & 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 tested various facets throughout the facility which did not reach at least 105 degrees.
POC Due Date: 02/21/2024
Plan of Correction
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Water heater will be adjust and verification will be sent to LPA.
Type A
Section Cited
CCR
87309(a)(1)
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 which poses an immediate health, safety or personal rights risk to persons in care. In an unlocked kitchen drawer LPA observed a screw driver & hammer. I cabinet LPA observed degrease spray.
POC Due Date: 02/21/2024
Plan of Correction
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Items were removed and made inaccessible to residents.
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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 02/26/2024 01:13 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 II
FACILITY NUMBER: 247209199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

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. In an unlocked cabinet in the kitchen LPA observed medication for R1.
POC Due Date: 02/21/2024
Plan of Correction
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Medication was removed and made inaccessible to residents.
Type A
Section Cited
CCR
87355(e)
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:

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 an immediate health, safety or personal rights risk to persons in care. LPA reviewed LIS personnel report which did not have S1, S2, or S3 listed on the reports. S1, S2, & S3 are not associated with the current facility.
POC Due Date: 02/21/2024
Plan of Correction
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S1, S2, and S3 will not be able to work at the facility until proper clearance and or association has been completed.
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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/26/2024 01:13 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 II
FACILITY NUMBER: 247209199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87613(a)(2)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs.

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 reviewed staff files were did not have current training for specialized care needs.
POC Due Date: 03/01/2024
Plan of Correction
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Administrator will provide current training verification.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 reviewed staff files were did not have 20 hours of annual training.
POC Due Date: 03/01/2024
Plan of Correction
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Administrator will provide current training verification.
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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/26/2024 01:14 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 II
FACILITY NUMBER: 247209199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(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 in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed mold in resident's shower and mildew/mild ring in various toilets.
POC Due Date: 03/01/2024
Plan of Correction
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Administrator will clean items and send verification to LPA.
Type B
Section Cited
CCR
87465(d)
(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:

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.
POC Due Date: 03/01/2024
Plan of Correction
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Residents with PRN prescriptions need to have a current physician's report and PRN on file. 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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5