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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202604
Report Date: 09/24/2024
Date Signed: 09/24/2024 02:52:53 PM

Document Has Been Signed on 09/24/2024 02:52 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:REINDOLLAR ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
275202604
ADMINISTRATOR/
DIRECTOR:		ADLER, WENDYFACILITY TYPE:
735
ADDRESS:301 REINDOLLAR AVETELEPHONE:
(831) 372-8002
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 4CENSUS: 4DATE:
09/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Administrator Wendy AdlerTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 9/24/24 Licensing Program Analysts (LPAs) B. Miranda & R. Bruce arrived at the facility unannounced to conduct a case management visit regarding a medication error. LPAs introduced themselves and explained the reason for the visit. Staff allowed LPAs into the facility and Administrator was contacted and arrived shortly after.

Missed medication was logged and destroyed at the facility for R1. Destruction log was completed correctly.

Records show S1 last received medication training by DSP on 8/26/2022. S1's last training was over a year old. Staff should have training from a licensed professional, and reviewed by licensed professional annually.

Deficiency found with staff training and citation issued.

Exit interview conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Wendy Adler.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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 2
Document Has Been Signed on 09/24/2024 02:52 PM - It Cannot Be Edited


Created By: Brianna Miranda On 09/24/2024 at 02:39 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: REINDOLLAR ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 275202604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
80075(b)(A)(2)(B)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(A) In ARFs, facility staff must receive training from a licensed professional. 2. The licensee ensures that the licensed professional reviews staff performance as the licensed professional deems necessary, but at least once a year.
(B) All staff training shall be documented in the facility personnel files.
This requirement is not met as evidenced by:
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Administrator stated training will be conducted and documented. Verification will be provided to LPA by due date. Prior to dispensing S1's medication will be checked by Administrator for the next 30 days.
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Based on observation, interview, & record review the licensee did not comply with regulation listed above. S1 does not have annual training completed. S1 did not distribute medication properly which lead to R1 missing their medication.
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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: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
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