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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202497
Report Date: 01/31/2023
Date Signed: 02/13/2023 09:20:23 PM


Document Has Been Signed on 02/13/2023 09:20 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:MARIPOSA ASSISTED LIVINGFACILITY NUMBER:
275202497
ADMINISTRATOR:CARLOS CASTROFACILITY TYPE:
740
ADDRESS:1201 LA SALLE AVE.TELEPHONE:
(831) 324-4113
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY:15CENSUS: 12DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Caregiver - Stevanie RamsaranTIME COMPLETED:
03:10 PM
NARRATIVE
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On 1/31/2023 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a required 1 year annual inspection. LPA met with S1 & S2. Administrator (AD) Carlos Castro and Manager Gabriella Espinoza were not available to meet in person. Tour was completed and S2 was authorized to sign documents. LPA was greeted and allowed entry into the facility.

LPA toured kitchen. During the tour LPA observed food stored in containers without being properly labeled in the refrigerator. LPA observed pest poisons & cleaning supplies in the kitchen area which were accessible to residents. LPA observed a broken shelf in the cabinet where pots & pans are kept. LPA observed knives and other sharps which were not locked away and are accessible to residents. LPA observed multiple expired non-perishable items and dead insects in the pantry. LPA observed frozen food which had been freezer burn. LPA observed the dish washer having mildew and a pungent odor. Foggers were stored in a cabinet where food is stored.

Fire extinguishers were last serviced 9/20/2022. Water temperature in the kitchen read as 110 degrees Fahrenheit. LPA observed one exit as being obstructed by a wheelchair and other items.

LPA observed bedrooms as clean and free from clutter. LPA observed one common shower and one private shower in a shared bedroom as having fecal matter in the shower. AD stated hospice gives showers and does not clean afterwards.

LPA observed 30-day supply of PPE. Medication room was locked and inaccessible to residents. LPA observed a cabinet outside the medication room, this cabinet had medication and was not locked. The hinges on the right side of the cabinet is broken leaving medication accessible to residents. PRN medication not in original container.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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 02/13/2023 09:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MARIPOSA ASSISTED LIVING
FACILITY NUMBER: 275202497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
87309 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.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 which poses an immediate health, safety or personal rights risk to persons in care. LPA observed poisons, lighter, and cleaning supplies in kitchen area not locked away and accessible to residents. LPA observed knives and others sharps as not locked and accessible to residents.
POC Due Date: 02/01/2023
Plan of Correction
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Items will be removed and pictures will be sent to LPA by 2/1/2023. Administrator will have a meeting by 2/14/23 to go over properly storing items that should not be accessible to residents. Administrator will send material of meeting to LPA by 2/14/2023
Type A
Section Cited
CCR
87555(b)(24)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored.

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 which poses an immediate health, safety or personal rights risk to persons in care. LPA observed Raid/poison and pest foggers in kitchen. Pest foggers were in cabinet with food items.
POC Due Date: 02/01/2023
Plan of Correction
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Items will be removed and pictures will be sent to LPA by 2/1/2023. Administrator will have a meeting by 2/14/23 to go over properly storing items that should not be accessible to residents. Administrator will send material of meeting to LPA by 2/14/2023
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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 02/13/2023 09:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MARIPOSA ASSISTED LIVING
FACILITY NUMBER: 275202497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 cabinet with resident's medication unlocked, hinges on right side of the cabinet are broken, leaving medication accessible to residents.
POC Due Date: 02/01/2023
Plan of Correction
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Medication will be removed and pictures will be sent to LPA by 2/1/2023. Administrator will have a meeting by 2/14/23 to go over properly storing items that should not be accessible to residents. Administrator will send material of meeting to LPA by 2/14/2023
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or 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 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 observe emergency exit at the end of a hallway being blocked by a wheelchair and other items.
POC Due Date: 02/01/2023
Plan of Correction
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Items will be removed and pictures will be sent to LPA by 2/1/2023. Administrator will have a meeting by 2/14/23 to go over exits remaining clear at all times. Administrator will send material of meeting to LPA by 2/14/2023
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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/13/2023 09:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MARIPOSA ASSISTED LIVING
FACILITY NUMBER: 275202497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
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.
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed self in kitchen, cabinet with medication broken, linen closet broken/off track, dish washing machine has mildew and pungent odor, bathrooms having fecal matter.
POC Due Date: 02/14/2023
Plan of Correction
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Redo linen closet, new dishwasher ordered, follow-up with staff regarding cleaning the bathroom. Administrator will have a meeting by 2/14/23 regarding proper cleaning at the facility. Administrator will send material of meeting to LPA by 2/14/2023
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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observe expired canned foods in pantry, and one freezer with freezer burned food. Food in containers were not properly labeled with dates.
POC Due Date: 02/14/2023
Plan of Correction
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Clean out pantry and freezer. Pictures will be sent to LPA. Administrator will have a meeting by 2/14/23 regarding properly storing food and disposing expired food by 2/14/2023. Administrator will send material of meeting to LPA by 2/14/2023
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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MARIPOSA ASSISTED LIVING
FACILITY NUMBER: 275202497
VISIT DATE: 01/31/2023
NARRATIVE
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LPA observed two staff members who need to be associated to the facility.

An exit interview was conducted with Administrator (AD) Carlos Castro over the phone, and a copy of this report, LIC809C, and LIC809D was signed by S2. This was authorized verbally over the phone with AD. LIC809, LIC809C, and LIC809Ds were read to AD over the phone and emailed to AD.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5