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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201839
Report Date: 02/27/2023
Date Signed: 03/02/2023 11:05:20 AM


Document Has Been Signed on 03/02/2023 11:05 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:EL CAMINO REAL MANORFACILITY NUMBER:
275201839
ADMINISTRATOR:CYRIL E. TUPINOFACILITY TYPE:
740
ADDRESS:3250 VISTA DEL CAMINO CIRCLETELEPHONE:
(831) 384-0390
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY:6CENSUS: 6DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator Martin UretaTIME COMPLETED:
03:00 PM
NARRATIVE
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On 2/27/23 at 11:35 a.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct an annual inspection. LPA was greeted by Administrator (AD) Martin Ureta, LPA explained the reason for the visit, and was allowed entry into the facility.

LPA toured the facility inside and out. Facility currently has 6 residents. There are 6 bedrooms & 3 bathrooms, 1 bedroom is used for staff, and 1 room is shared between two male residents. Water temperature was checked in one of the common bathrooms, water temperature read at 105.1 degrees Fahrenheit. LPA observed fire extinguisher in good stand and last serviced on 8/18/22.

LPA observed front door to be locked with a double deadbolt needing a key to unlock from the inside. LPA observed a stick being used to keep the back sliding door locked. LPA observed the door alarm was turned off for the backdoor. AD stated during the day the alarm is placed off and turned on at night.
LPA toured the kitchen and observed knives in an unlocked drawer and accessible to residents. LPA observed cleaning products under the sink which was unlocked. LPA observed 2 days worth of perishable food item, and insufficient amount of non-perishable items.
LPA observed medication locked and inaccessible to residents. LPA observed medication be prepared in advance and stored in other containers besides original container.
LPA observed the bathrooms free from clutter. One bathroom was observed to have water damage.

LPA observed residents in their rooms, except for one who was in the common area. LPA observed residents rooms to have adequate light and storage.
LPA reviewed 2 resident's profiles. LPA reviewed current mitigation plan for COVID. Facility is properly following COVID protocols.
Exit interview was completed, a copy of this report, LIC809C, and LIC809D were provided to AD.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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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: EL CAMINO REAL MANOR
FACILITY NUMBER: 275201839
VISIT DATE: 02/27/2023
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 03/06/2023

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/02/2023 11:05 AM - 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: EL CAMINO REAL MANOR
FACILITY NUMBER: 275201839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
87309 Storage Space
(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.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, due to leaving cleaning supplies/chemicals accessible to resident in care which poses an immediate health, safety or personal rights risk to persons in care. LPA observed unlocked cabinet under kitchen sink with chemicals, and knives not in locked cabinet.
POC Due Date: 02/28/2023
Plan of Correction
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All chemicals and knives will be locked and inaccessible to residents immediately. Staff meeting to remind staff to lock chemicals and knives.
Type A
Section Cited
CCR
87465(h)(5)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations 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 medication was removed from original packaging and placed in separate containers to distribute at a later time or the next day.
POC Due Date: 02/28/2023
Plan of Correction
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Facility will no longer store medication improperly. Administrator will retrain or implement a plan for facility. Verification of training or plan being implemented will be sent to LPA by 3/6/23.
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: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/02/2023 11:05 AM - 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: EL CAMINO REAL MANOR
FACILITY NUMBER: 275201839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
87705 Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview with administrator, and record review, the licensee did not comply with the section cited above, the facility did not obtain Fire Department approval to lock backsliding door with stick in sliding area of door or have a double deadbolt lock for the front door. These additional locks pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2023
Plan of Correction
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The double deadbolt will be replaced and cannot be used to lock the front door and the stick cannot be used in addition to the lock on the back sliding door.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4