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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201916
Report Date: 11/03/2022
Date Signed: 11/04/2022 09:49:27 AM

Document Has Been Signed on 11/04/2022 09:49 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:PARK RIDGE ADULT CARE HOME 2FACILITY NUMBER:
275201916
ADMINISTRATOR:NESTOR D. VALDEZFACILITY TYPE:
735
ADDRESS:1332 NEW HAMPSHIRE COURTTELEPHONE:
(831) 998-8552
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY: 6CENSUS: 6DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee, Nestor ValdezTIME COMPLETED:
03:30 PM
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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 Nestor Valdez Continual Administrator's Certification expires 11/21/2022. There are currently 6 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, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 109 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA confirmed all staff present are background cleared. LPA confirmed staff present has COVID Vaccine cards or exemptions on file.

The fire extinguisher located inside the upstairs hallway near all three resident bedrooms has not been serviced since August 2021.

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-E 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 Nestor Valdez and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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Document Has Been Signed on 11/04/2022 09:49 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/03/2022 at 02:49 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: PARK RIDGE ADULT CARE HOME 2
FACILITY NUMBER: 275201916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)

80020 Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in the only fire extinguisher inside the facility located in the upstairs hallway has not been serviced in more than a year (08/2021) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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The Licensee will send photo proof of new fire extinguisher by 11/04/2022 POC date.
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: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


LIC809 (FAS) - (06/04)
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