247209204-12-19-2022-24-AS-BMIA-CMA35V-20221219165723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247209204
Report Date: 12/16/2022
Date Signed: 12/19/2022 04:57:30 PM

Document Has Been Signed on 12/19/2022 04:57 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:	ANAYA ELDER CARE LLC		FACILITY NUMBER:	247209204
ADMINISTRATOR:	FERNANDEZ, DODERLEIN ANAYA		FACILITY TYPE:	740
ADDRESS:	2058 DANTE CT		TELEPHONE:	(951) 772-9113
CITY:	LOS BANOS	STATE: CA	ZIP CODE:	93635
CAPACITY:	6	CENSUS: 1	DATE:	12/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:12 PM
MET WITH:	Administrator- Doderlein Anaya Fernandez		TIME COMPLETED:	04:00 PM

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On 12/16/22 at 1:12 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced. LPA was greeted by Administrator Doderlein Anaya Fernandez and allowed entry into the facility. Administrator is live in staff with her husband and minor child. Caregiver and designee administrator S1 was also at the facility.

LPA was not pre-screened for COVID. There did not appear to be a designated area for Covid screening.

Facility was toured inside and out. The house consists of 6 bedrooms and 2 bathrooms. One bedroom is for live in staff, 2 bedrooms are available for single residents, 2 bedrooms are available for residents to share the rooms. Current census is 1. Resident was present in the facility during the inspection. Resident was in the common area asleep. Current resident resides in a share room with no current roommate.

Entry way of the facility was free from any obstructions and had a log in book.

LPA observed kitchen as being clean and free of clutter. Facility has 2-days’ worth of perishable items and 7-days’ worth of non-perishable items. Knives were locked and inaccessible to resident. Cleaning products were found under the sink, S1 was doing dishes TA was issued to remind cleaning products are to remain inaccessible to residents at all times. Water temperature read at 106.5 degrees Fahrenheit.

LPA observed R1s bedrooms was clean and free of clutter, R1 had adequate storage space for belongings and good lighting in the room. LPA observed the other bedrooms as clean, free from clutter, and readily available for residents.

See LIC809C for continuation of this report

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

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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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: ANAYA ELDER CARE LLC	FACILITY NUMBER: 247209204
	VISIT DATE: 12/16/2022

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Bathrooms were observed as being clean and free of clutter.

LPA observed fire extinguishers are current with service and in good standing condition. LPA observed smoke alarm in working conditions. All doors leading out of the facility have alarms.

Backyard was clean and free from any obstructions blocking the entrance.

An exit interview was conducted, and a copy of this report dated 12/16/2022 along with LIC809D. Plan of Correction (POC) were discussed. Appeal Rights was provided to Administrator Doderlein Anaya Fernandez whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/19/2022 04:57 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: ANAYA ELDER CARE LLC	FACILITY NUMBER: 247209204
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, 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: 12/30/2022
	Plan of Correction
1 2 3 4	Administrator will have a gate to make tools inaccessible in the garage or place all tools in locked container/area inaccessible to residents. Administrator will provide pictures to LPA to verify correction.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

LIC809 (FAS) - (06/04)

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