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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201878
Report Date: 01/24/2023
Date Signed: 01/25/2023 01:13:45 PM

Document Has Been Signed on 01/25/2023 01:13 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:GLENDORA GUEST HOMEFACILITY NUMBER:
275201878
ADMINISTRATOR:HONESTO R. FERNANDEZFACILITY TYPE:
735
ADDRESS:1905 GLENDORA WAYTELEPHONE:
(831) 443-8746
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 5DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Honesto FernandezTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee Honesto Fernandez, Continual Administrator's Certification expires 03/30/2023 There are currently 5 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. There is a locked storage for medications.

Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA confirmed all staff present is background cleared.

LPA Hurt observed the carpet in two resident bedrooms to be extremely dirty. LPA observed two dressers holding up a TV in the living area, and one dresser missing a drawer. LPA Hurt observed the bathroom vanity mirror to be broken and falling. Upon entry to the facility LPA Hurt observed the temperature on thermostat to be 58 degrees. LPA observed the fire extinguisher has not been serviced within the year, last serviced 05/2021.LPA Hurt observed several food containers, and Ziploc bags with raw frozen fish inside the refrigerator with no label or date.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.
LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610 the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee Honesto Fernandez, and a copy of report along with appeals rights left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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 4
Document Has Been Signed on 01/25/2023 01:13 PM - It Cannot Be Edited


Created By: Sarah Hurt On 01/24/2023 at 12:02 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: GLENDORA GUEST HOME
FACILITY NUMBER: 275201878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
87555 General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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 in LPA observed several food items inside the facility refrigerator inside containers with no labels or dates, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2023
Plan of Correction
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Licensee will conduct staff training on food service requirements and submit proof to LPA by 02/07/2023 POC date.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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 in LPA observed dressers with mssing drawers, bathroom vanity mirror broken, and carpet in resident bedrooms to be extremely dirty, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2023
Plan of Correction
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Licensee will fix furnishings, and send proof to LPA by POC date of 02/08/2023
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:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 01/25/2023 01:13 PM - It Cannot Be Edited


Created By: Sarah Hurt On 01/24/2023 at 12:12 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: GLENDORA GUEST HOME
FACILITY NUMBER: 275201878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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 in LPA observerd the fire extinguisger as last serviced 05/2021 more than a year, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2023
Plan of Correction
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Licensee will send proof of currently serviced fire extinguisher to LPA by POC date of 01/25/2023.
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 Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/25/2023 01:13 PM - It Cannot Be Edited


Created By: Sarah Hurt On 01/24/2023 at 12:14 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: GLENDORA GUEST HOME
FACILITY NUMBER: 275201878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(b)(1)
87303 Maintenance and Operation

87303(b)(1) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
(b) A comfortable temperature for residents shall be maintained at all times.
(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).
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 in LPA observed the facility temperature to be 57 degrees upon entrance of the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2023
Plan of Correction
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Licensee turned heat on during visit, and will conduct staff training on regulation 87303 (b)(1) and send proof to LPA by POC date of 02/01/2023
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 Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023


LIC809 (FAS) - (06/04)
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