<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209204
Report Date: 09/09/2024
Date Signed: 09/09/2024 12:29:01 PM


Document Has Been Signed on 09/09/2024 12:29 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:
09/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Administrator- Doderlein Anaya FernandezTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/9/2024 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management visit. LPA introduced herself and explained the reason for the visit. LPA met with Administrator Doderlein Anaya Fernandez.

On 9/5/2024 at 3:44 pm LPA requested AD to provide an explanation for the bruising on R1's right arm. On 9/5/2024 LPA searched for the incident reports regarding R1's bruises but was unable to locate. AD responded on 9/6/2024 at 8:44 am stating incident reports were previously submitted via fax. LPA did not observed a fax confirmation on the incident reports included in the email. The incident reports included on 9/6/2024 email indicated the family was informed of the bruising verbally. According to Title 22, Division 6, Chapter 8 the Dept. and responsible party should be notified in writing within 7 days of the occurrence. AD stated verbal notice was given to family members..

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Doderlein Anaya Fernandez.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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 2


Document Has Been Signed on 09/09/2024 12:29 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: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2024
Section Cited
CCR
97211(a)(1)

1
2
3
4
5
6
7
87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator has dedicated fax line. Policy will be implemented to given written notice to responsible parties.
8
9
10
11
12
13
14
Based on observation, interview, & record review the licensee did not comply with the regulation listed above which poses a potential health, safety, or personal rights risk to residents in care. AD indicated on the incident reports the family was verbally informed of the incidents.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2