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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200248
Report Date: 08/29/2023
Date Signed: 09/06/2023 10:05:48 AM

Document Has Been Signed on 09/06/2023 10:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:C & D CARE FACILITY # 2FACILITY NUMBER:
275200248
ADMINISTRATOR:DAISY PARCASIOFACILITY TYPE:
735
ADDRESS:1144 ROCKHAVEN COURTTELEPHONE:
(831) 443-1637
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 6DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Facility House Manager, Susana ReyesTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Facility House Manager, Susana Reyes Continual Administrator's Certification for Daisy Parcasio expires 07/06/2023. Administrator Daisy Parcasio has sent in her Administrators certificate renewal. There are currently 6 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. Facility water temperature was tested at 114 degrees. First Aid kit is on site and complete.

LPA Hurt observed several containers inside facility kitchen refrigerator without labels or dates. LPA Hurt observed expired cup of noodles inside facility cabinets. LPA Hurt observed several corners of the facility living area to be cluttered with storage totes, and stacks of paperwork. The facility Emergency Disaster Plan has not been signed as reviewed since August 2021.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Facility House Manager, Susana Reyes and copy of report left at facility

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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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Document Has Been Signed on 09/06/2023 10:05 AM - It Cannot Be Edited


Created By: Sarah Hurt On 08/29/2023 at 12:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: C & D CARE FACILITY # 2
FACILITY NUMBER: 275200248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2023
Section Cited
CCR
80023(a)

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80023 Disaster and Mass Casualty Plan (a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action. The following requirement has not been met as evidenced by:
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Licensee agrees to update facility Emergency Disaster plan and submit proof to LPA by 09/07/23.
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Based on observation the facility does not have an updated Emergency Disaster Plan which poses a potential health, safety, or personal rights risk to residents in care.
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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
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
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