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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200905
Report Date: 05/17/2023
Date Signed: 05/23/2023 10:39:53 PM

Document Has Been Signed on 05/23/2023 10:39 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:SOLEDAD SVSFACILITY NUMBER:
275200905
ADMINISTRATOR:DIANA CASTANEDAFACILITY TYPE:
775
ADDRESS:757 FRONT STREETTELEPHONE:
(831) 678-9431
CITY:SOLEDADSTATE: CAZIP CODE:
93960
CAPACITY: 60CENSUS: 30DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Administrator- Diana CastanedaTIME COMPLETED:
04:00 PM
NARRATIVE
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On 5/17/23 at 11:50 a.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an annual inspection. LPA was greeted by staff member and Administrator (AD) Diana Castaneda was notified. Tour was conducted with Administrator (AD) Diana Castaneda.

LPA toured the facility inside and out. LPA observed fire extinguishers to be last serviced 8/10/22 and in good standing. LPA checked water temperature in one of the men’s bathrooms which read at 109.7 degrees Fahrenheit.

Drinking water is provided to clients and staff from water dispensers.

Facility provided verification of fire drills completed at the facility which were conducted in a timely manner. LPA observed one emergency exit to not be clear and free from obstruction. Citation issued under Title 22, 82020 Fire Clearance

LPA observed clients interacting with staff members. Sample of staff profiles were reviewed. LPA observed current CPR/First Aid certifications in the staff files. Sample of client profiles were reviewed.

Samples of MARs and Centrally Stored Medication Log was reviewed.

LPA observed uncleared staff member at the facility. Citation issued under Title 22, 82019 Criminal Record Clearance

Citations were issued for the deficiencies.

Sample of staff's current DSP training, Med Tech training, mandated reporting policy will be provided to LPA by end of business day 5/22/23.

Exit interview was conducted an copy of LIC809, LIC809D, LIC421BG, and appeal rights were provided to Administrator.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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 05/23/2023 10:39 PM - It Cannot Be Edited


Created By: Brianna Miranda On 05/17/2023 at 03:13 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: SOLEDAD SVS
FACILITY NUMBER: 275200905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82020
Fire Clearance
All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed one of the back emergency exits to not be clear and free from obstruction.
POC Due Date: 05/18/2023
Plan of Correction
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Administrator will provide pictures of emergency exit way cleared to LPA.
Type A
Section Cited
CCR
82019(j)
Criminal Record Clearance
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 82066, Personnel Records.

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 an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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Staff member R1 will not return to the facility until full background clearance has been completed.
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:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
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