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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202077
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:24:09 PM

Document Has Been Signed on 10/05/2023 12:24 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:SVS MARINA ADULT DAY PROGRAMFACILITY NUMBER:
275202077
ADMINISTRATOR:RITA FAATUAIFACILITY TYPE:
775
ADDRESS:330 RESERVATION RD. STE. DTELEPHONE:
(831) 582-2961
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 60CENSUS: 41DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Administrator Rita FaatuaiTIME COMPLETED:
12:30 PM
NARRATIVE
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On 10/5/23 at 8:35 a.m. Licensing Program Analyst B.Miranda entered the facility to conduct an unannounced Annual Inspection. LPA met with Administrator Rita Faatuai and explained the reason for the visit.
Upon arrival LPA observed clients arriving to the facility and interacting with staff while preparing for the day. Staff were assisting clients with putting their lunches away and getting into the correct activity rooms.

LPA observed facility to be free from clutter, odor free, and exits to be obstruction free. LPA observed the movie room carpet to be soiled and needing to be cleaned. LPA observed mildew in the toilet located in the women's bathroom.

LPA observed all cleaning supplies in a secured and locked area. AD stated the facility does not have sharps or medication at the facility.

LPA observed fire extinguishers which were last serviced 1/9/23 and are in good standing. Water temperature was checked in the kitchen area and read at 80.6 degrees F. Smoke detectors are wired into the facility and will have annual service completed this month. Carbon monoxide reader was tested and is in good standing.

LPA reviewed a sample of staff files. Staff training verification was not provided at this time.

LPA reviewed a sample of client files which are current and up to date.

Facility has an illness prevent plan in place but needs to be updated to comply with infection control plan. Facility also has to update their disaster plan.

Exit interview was completed and a copy of the report LIC809, LIC809D, and appeal rights were provided to AD Rita Faatuai

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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 3
Document Has Been Signed on 10/05/2023 12:24 PM - It Cannot Be Edited


Created By: Brianna Miranda On 10/05/2023 at 11:54 AM
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: SVS MARINA ADULT DAY PROGRAM
FACILITY NUMBER: 275202077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 carpet in movie room to be soiled, toilet in women's bathroom needs to be cleaned.
POC Due Date: 10/12/2023
Plan of Correction
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Pictures will be sent to verify items have been cleaned.
Type B
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 water temperature in the kitchen area to be 80.6, and in the women's bathroom to be 78.4 which are both below the requirement.
POC Due Date: 10/12/2023
Plan of Correction
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Administrator will provided verification of water heater delivering correct water temperature.
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: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/05/2023 12:24 PM - It Cannot Be Edited


Created By: Brianna Miranda On 10/05/2023 at 11:54 AM
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: SVS MARINA ADULT DAY PROGRAM
FACILITY NUMBER: 275202077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, & record reviews, 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 unable to provide verification of current training for staff or Administrator. Specific training also needs to be updated for clients with restricted health conditions.
POC Due Date: 10/12/2023
Plan of Correction
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Verification of training will be provided 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 Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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