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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708852
Report Date: 07/19/2023
Date Signed: 07/19/2023 02:34:03 PM


Document Has Been Signed on 07/19/2023 02:34 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:MAGALLANES REST HOMEFACILITY NUMBER:
270708852
ADMINISTRATOR:MAGALLANES, LYDIAFACILITY TYPE:
740
ADDRESS:193 LILLIAN PLACETELEPHONE:
(831) 917-3584
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY:6CENSUS: 1DATE:
07/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Administrator- Lydia MagallanesTIME COMPLETED:
02:30 PM
NARRATIVE
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On 7/19/23 at 10:33 a.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct an annual inspection. LPA was greeted by Administrator (AD) and allowed entry into the facility. LPA explained the reason for the visit.

LPA toured the facility and found all doorways to be clear and free from obstruction. Water temperature in bathroom read at 110.8 degrees Fahrenheit. Smoke and carbon monoxide detector were tested and are in working condition. New fire extinguisher was purchased on 4/30/23. LPA observed medication cabinet to not be properly locked.

Facility has 3 bedrooms and 2 bathrooms. Administrator lives on site and there is currently only 1 resident.
Administrator stated at this time they will continue to only have 1 resident, and be the primary caregiver for the resident. Resident's file was reviewed and is incomplete. Administrator's file was reviewed and is incomplete. Training for backup staff is incomplete.

LPA observed resident interacting with Administrator and one staff member.

Facility is odor and pest free, administrator was advised facility needs be de-cluttered.
LPA observed resident's room to be properly furnished with adequate storage and lighting. LPA observed proper amount of perishable and non-perishable food items.



Exit interview was conducted and a copy of this report was provided to Administrator Lydia Magallanes.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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 3


Document Has Been Signed on 07/19/2023 02:34 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: MAGALLANES REST HOME
FACILITY NUMBER: 270708852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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: 07/28/2023
Plan of Correction
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Administrator will provide a plan to create and maintain personnel files.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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: 07/28/2023
Plan of Correction
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Administrator will provide a copy of emergancy & disaster plan.
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: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/19/2023 02:34 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: MAGALLANES REST HOME
FACILITY NUMBER: 270708852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview with administrator, the licensee did not comply with the section cited above. Which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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3
4
Medication cabinet was not locked. Proper lock will be placed on cabinet and verificaiton will be sent to LPA.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
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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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3