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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201839
Report Date: 02/16/2024
Date Signed: 02/18/2024 09:44:25 PM


Document Has Been Signed on 02/18/2024 09:44 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:EL CAMINO REAL MANORFACILITY NUMBER:
275201839
ADMINISTRATOR:URETA, MARTINFACILITY TYPE:
740
ADDRESS:3250 VISTA DEL CAMINO CIRCLETELEPHONE:
(831) 384-0390
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY:6CENSUS: 6DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator- Martin UretaTIME COMPLETED:
03:15 PM
NARRATIVE
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On 2/16/24, Licensing Program Analyst (LPA) B. Miranda conducted a required unannounced Annual Visit. LPA introduced self, stated purpose of visit, and was allowed entrance by Administrator Martin Ureta.

LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPA observed the facility to be clean, free from clutter, and odor free.

All fire exit routes were free and clear of obstructions. Medications are stored in a locked cabinet in the kitchen. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility has 6 bedrooms and 3 bathrooms. 5 room are occupied by residents and 1 of the rooms is shared. LPA observed the rooms to be properly furnished with adequate storage space.
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Fire extinguishers have been services as of 8/16/23 and are in good standing. Smoke alarms are in working condition. Carbon monoxide detector was tested and is in working condition. Water temperature was checked in the resident's bathroom and read at 105.1 degree Fahrenheit.

LPA reviewed a sample of employee files which were missing current training verification and only the Administrator is CPR certified. Facility was not able to provide current Certificate of Liability Insurance. LPA reviewed a sample of resident files.

Deficiencies were cited.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Martin Ureta.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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 3


Document Has Been Signed on 02/18/2024 09:44 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: EL CAMINO REAL MANOR
FACILITY NUMBER: 275201839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

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/posed a potential health, safety or personal rights risk to persons in care. Liability insurance on file was effective 9/20/2022 and expired 9/20/2023. There is no record of a current policy at the facility.
POC Due Date: 02/23/2024
Plan of Correction
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Insurance policy will be updated or purchased. Verification will be sent to LPA.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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. Administrator is at the facility most of the time, but does have to leave from time to time. During the leave to run errands additional staff is not CPR certified.
POC Due Date: 02/23/2024
Plan of Correction
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Additional staff will be CPR certified, verification will be sent to LPA.
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: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/18/2024 09:44 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: EL CAMINO REAL MANOR
FACILITY NUMBER: 275201839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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. Administrator was not able to provide current training verification for staff.
POC Due Date: 03/01/2024
Plan of Correction
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Administrator will conduct training's and sent verification to LPA.
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: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3