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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201863
Report Date: 08/14/2023
Date Signed: 08/15/2023 06:47:28 AM

Document Has Been Signed on 08/15/2023 06:47 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:ANJELICA'S VILLAFACILITY NUMBER:
275201863
ADMINISTRATOR:NERISSA RAMOSFACILITY TYPE:
740
ADDRESS:555 FRANCIS AVETELEPHONE:
(831) 899-2644
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY: 40CENSUS: 16DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Caregiver- Sonia SabTIME COMPLETED:
06:45 PM
NARRATIVE
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On 8/14/23 at 12:32 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct an annual inspection. LPA met with Caregiver Sonia Sab. Sonia attempted to contact the administrator Nerissa Ramos, but was able to come to the facility.

LPA toured the facility inside and out.

LPA toured the kitchen and observed 2-days worth of perishable food items and 7-days worth of non-perishable food items.
LPA observed cleaning products to be stored with eating utensils. Insect spray & disinfecting spray stored on Kitchen tray with cooking utensils. LPA observed expired canned food items, expired sandwich meat in the fridge, open food in fridge/freezers not labeled properly. These deficiencies will be cited under Title 22, Division 6, Chapter 8. LPA also observed outside door from kitchen to be left open and flies were in the kitchen.

LPA observed water temperature in one of the common bathrooms to read at 121.6 degrees F. LPA observed food inside a bathroom cabinet. Dementia residents had access to shampoo, body wash, and prescription mouth wash.
LPA did not observe plan of operation or plan of operation for residents with dementia. Reappraisal plans were not completed for residents who returned from the hospital.


Exit interview was conducted. A copy of LIC809, LIC 809Ds, and a copy of appeal rights were provided to Caregiver Sonia Sab.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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 5
Document Has Been Signed on 08/15/2023 06:47 AM - It Cannot Be Edited


Created By: Brianna Miranda On 08/14/2023 at 05:30 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: ANJELICA'S VILLA
FACILITY NUMBER: 275201863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87308(c)
Resident and Support Services
(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, 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 food being stored in a bathroom cabinet.
POC Due Date: 08/15/2023
Plan of Correction
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Facility will removed food from the bathroom. Verification will be sent to LPA.
Type A
Section Cited
CCR
87309(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, 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 shampoos and body wash soaps accessible to residents with dementia. One resident had access to a prescription mouth wash.
POC Due Date: 08/15/2023
Plan of Correction
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Caregiver will inform Adminsitrator of the situation. Plan will be provided to LPA, plan will be completed by 8/25/23.
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 Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/15/2023 06:47 AM - It Cannot Be Edited


Created By: Brianna Miranda On 08/14/2023 at 05:30 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: ANJELICA'S VILLA
FACILITY NUMBER: 275201863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, 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 insect spray in kitchen with cooking utensils. Cleaning sprays were stored with eating utensils.
POC Due Date: 08/15/2023
Plan of Correction
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Products will be moved to specific area for cleaning supplies. Pictures will be sent to LPA.
Type A
Section Cited
CCR
87555(b)(8)
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, 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 expired canned food and expires sandwich meat at the facility. LPA observed food containers with no dates and not labeled.
POC Due Date: 08/15/2023
Plan of Correction
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Expired food will be removed. Pictures 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 Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/15/2023 06:47 AM - It Cannot Be Edited


Created By: Brianna Miranda On 08/14/2023 at 05:30 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: ANJELICA'S VILLA
FACILITY NUMBER: 275201863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain 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. Facility has no Plan of Operation on file.
POC Due Date: 08/25/2023
Plan of Correction
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Facility will create or obatin a copy of plan of operation and provide to LPA.
Type B
Section Cited
CCR
87208(c)
Plan of Operation
(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).

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.Facility has no plan of operation for residents with dementia.
POC Due Date: 08/25/2023
Plan of Correction
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Facility will create or obatin a copy of plan of operation for resdients with dementia and provide 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 Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/15/2023 06:47 AM - It Cannot Be Edited


Created By: Brianna Miranda On 08/14/2023 at 05:30 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: ANJELICA'S VILLA
FACILITY NUMBER: 275201863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

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. When residents return from the hospital there is no pre-appraisal being completed.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator will create a procedure to verify reappraisal has been completed for residents.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, 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. LPA observed kitchen door to outside is left open which allows flies and other insects inside. Staff stated door is left open because it gets hot. LPA observed flies in the kitchen.
POC Due Date: 08/25/2023
Plan of Correction
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Kitchen staff will keep door closed and use fan to circulate air. 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 Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 5 of 5