<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202689
Report Date: 01/31/2023
Date Signed: 07/07/2023 10:02:45 AM


Document Has Been Signed on 07/07/2023 10:02 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SONGBIRD IN THE COUNTRYFACILITY NUMBER:
275202689
ADMINISTRATOR:MAZIREK, BETHFACILITY TYPE:
740
ADDRESS:15961 TORO HILLS AVENUETELEPHONE:
(831) 998-8708
CITY:SALINASSTATE: CAZIP CODE:
93908
CAPACITY:12CENSUS: 10DATE:
01/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee, Mathew Mazerik TIME COMPLETED:
02:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a Case Management (Deficincies) visit.. LPA Hurt met with Licensee Mathew Mazirek and explained the purpose of today's visit.

LPA Hurt reviewed Special Incident Report documenting at 4:30 a.m. on 01/03/2023 a facility caregiver heard Resident 1's bed alarm go off and upon checking on her found her on the floor near her bed and night stand. The care giver saw Resident 1 had hit her head. The facility staff called the ambulance and Resident 1 was transferred to Natividad Hospital.

This incident was not reported to Community Care Licensing.

The following Deficiencies are being cited Per Title 22 Regulations.

A copy of this report along with Appeals rights Provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
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 2


Document Has Been Signed on 07/07/2023 10:02 AM - 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: SONGBIRD IN THE COUNTRY
FACILITY NUMBER: 275202689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2023
Section Cited
CCR
87211(a)

1
2
3
4
5
6
7
87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. The following requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Licensee will conduct staff training on reporting requirements and submit to LPA by 02/15/2023 POC date.
8
9
10
11
12
13
14
Licensee did not report Resident 1's fall to Licensing which poses a potential health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Sarah HurtTELEPHONE: 559-243-8080
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 2