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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201863
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:59:32 PM

Document Has Been Signed on 08/22/2024 01:59 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:ANJELICA'S VILLAFACILITY NUMBER:
275201863
ADMINISTRATOR/
DIRECTOR:		NERISSA RAMOSFACILITY TYPE:
740
ADDRESS:555 FRANCIS AVETELEPHONE:
(831) 899-2644
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY: 40CENSUS: 18DATE:
08/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:47 AM
MET WITH:Licensee Nerissa RamosTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 8/22/2024 Licensing Program Analyst (LPA) B. Miranda arrived unannounced at the facility to conduct a Continual Annual Inspection. LPA introduced herself and explained the reason for the visit. LPA met with Licensee Nerissa Ramos.
When LPA entered the facility the auditory alarm was not on, facility serves dementia residents. On the 8/7/2024 visit auditory alarms were also not on. Smoke detectors and alarms were serviced on 8/19/2024 by Tri-County Fire Protection, and passed inspection. Carbon monoxide detectors were tested today 8/22/2024 and are in working condition.
On 8/7/2024 LPA observed staff (S1) was not properly cleared and was required to leave the facility. Civil Penalty.
LPA reviewed R1's medications, and observed the following issues:
Tramadol HCL 50 MG Tablet- Marked on Centrally Stored Log and prescription as starting on 8/15/2024, the count was off, narcotics log has 3 different entries for two for 8/15/2024 & one for 8/16/2024.
Lactulose 10 GM/15 ML Centrally Stored Medication Log has medication start date of 8/9/2024, medication label was marked as staring on 8/15/2024.
Docusate Sodium 50 MG/5 ML was labeled on the bottle with a start date of 7/24/2024, logged on the Centrally Stored Log as starting 8/9/2024.
Guaifenesin 100 MG/5ML (PRN) RX number was logged incorrectly on the Centrally Stored Medication Log.
Facility has a licensed capacity for 40, and has not had consultant pharmacist or nurse review the medication management program.
Deficiencies were noted and citations were issued under Title 22.
Licensee will follow-up with manufacture date for salad dressing and policy for medication destruction log. Due 9/6/2024
Exit interview was conducted and a copy of this report LIC809, LIC809D, LIC421BG, and appeal rights were provided to was emailed to Licensee Nerissa Ramos
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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 08/22/2024 01:59 PM - It Cannot Be Edited


Created By: Brianna Miranda On 08/22/2024 at 01:06 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: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

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. LPA observed S1 working in the facility without proper background clearance. Licensee stated S1 has worked at the facility for less than a year.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee was informed S1 could not work at the facility until the background clearance was completed. On 8/7/2024 S1 was informed to leave the facility and could return once background clearance is completed.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

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. LPA observed R1's Centrally stored medication log, and observed the log to not be completed properly.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee will conduct medication training and provide verification of training to LPA. Licensee will email LPA to provide training date.
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: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2024 01:59 PM - It Cannot Be Edited


Created By: Brianna Miranda On 08/22/2024 at 01:32 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: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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. During both visits on 8/7/2024 & 8/22/2024 LPA observed no auditory alarms to be on the exits of the facility which lead to the parking lot.
POC Due Date: 09/06/2024
Plan of Correction
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Licensee will have a staff meeting and explaining auditory alarms will remain on. Verification will be sent to LPA.
Type B
Section Cited
HSC
1569.69(g)
§1569.69 Employees assisting residents with self-administration of medication; training requirements
(g) Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility’s medication management program and procedures at least twice a year.
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. Licensee stated there have been no consults regarding the facility's medication management program.
POC Due Date: 09/06/2024
Plan of Correction
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Licensee will schedule consult with pharmacy to have medication program reviewed. 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: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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