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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209204
Report Date: 08/04/2023
Date Signed: 08/04/2023 03:02:27 PM


Document Has Been Signed on 08/04/2023 03:02 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 LLCFACILITY NUMBER:
247209204
ADMINISTRATOR:FERNANDEZ, DODERLEIN ANAYAFACILITY TYPE:
740
ADDRESS:2058 DANTE CTTELEPHONE:
(951) 772-9113
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:6CENSUS: DATE:
08/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Staff Kirsten YuTIME COMPLETED:
03:10 PM
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On 8/4/23 at 1:38 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management for a death report the Department previously received. LPA was greeted by staff member Kirsten Yu and allowed entry into the facility. Kirsten is the back up administrator for the facility.

LPA reviewed R1's file. R1 was receiving home health care with Compassionate Care. Pressure wounds were noted. LPA spoke with representative from Compassion Care who verified the pressure wounds were not over stage 2.

On the night of 6/4/23 through the morning of 6/5/23 R1 was checked on periodically. When Kirsten checked on the resident at about 5:00 a.m. she was unable to find a pulse. Kirsten called 911 immediately. The police arrive first, the fire department arrived after and tried to revive the resident. Fire Department announced time of death.

During today's visit on 8/4/23 LPA observed the two residents in the facility. One resident was in their room and the other was in the living room watching television.

LPA did not observe any deficiencies and no citations were issued today.

Exit interview was completed and copy of this report (LIC809) was provided to Kirsten Yu.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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