275202752-4-4-2023-24-AS-BMIA-CQKNG7-20230404102639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 275202752
Report Date: 03/30/2023
Date Signed: 04/04/2023 10:26:53 AM

Document Has Been Signed on 04/04/2023 10:26 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:	MESSINGER CARE HOME		FACILITY NUMBER:	275202752
ADMINISTRATOR:	ESTAMO, JUANITO JR		FACILITY TYPE:	740
ADDRESS:	3121 MESSINGER DR		TELEPHONE:	(831) 883-9386
CITY:	MARINA	STATE: CA	ZIP CODE:	93933
CAPACITY:	6	CENSUS: 6	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:37 PM
MET WITH:	Caregiver- S1		TIME COMPLETED:	05:10 PM

NARRATIVE

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On 3/30/2023 at 1:37 p.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility to conduct a required unannounced annual inspection. LPA was greeted by staff S1. Administrator (AD) was contacted, and AD’s wife S2 was informed S1 would be conducting the annual inspection since AD was not able to make it at this time.

LPA observed two caregivers at the facility. S3 is not associated with the facility which will result in a citation Per California Code of Regulations, Title 22, Division 6, Chapter 8, 87355 Criminal Record Clearance.

LPA toured the facility inside and out. Entry way was clear and free from obstructions. Temperature in the facility was comfortable. Facility currently has 6 residents. Facility has 5 bedrooms and 2 bathrooms. Two residents share a room and the other 4 have their own rooms. All rooms were observed to have proper lighting, furniture, and storage for residents.

LPA observed kitchen to be clean and free from clutter. Knives were observed to be locked away and inaccessible to residents. LPA observed sufficient seven day non-perishable food items and two days’ worth of perishable food items at the facility.

Medication was observed to be locked and inaccessible to residents. Two resident files and medication logs were reviewed. LPA observe medication log not being signed off as medication is taken, S1 stated the log is signed off at the end of shift.

LPA observed bathrooms to be clean, free from clutter, and odor free. Bathrooms were observed to have pull bars and non-slip mats. Water temperature was check in the common bathroom and read at 112.2 degrees Fahrenheit.

See LIC809C

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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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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: MESSINGER CARE HOME	FACILITY NUMBER: 275202752
	VISIT DATE: 03/30/2023

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Facility has 1 fire extinguisher which is current, in good standing, and last serviced 6/6/2022. Smoke detectors were checked and observed to be in working condition. LPA observed fire clearance exits from inside the house to be clear and free from obstruction. LPA observed the fire exits from the back yard to be obstructed. One exit is obstructed with part of a pellet and the others with a screen door (pictures taken).Citation will be issued Per California Code of Regulations, Title 22, Division 6 Chapter 8 87202 Fire Clearance.

Exit interview was conducted and copies of this report, LIC809C, LIC809D, and LIC421BG were provided to S1.

At about 4:45 S4 arrived to the facility who is also not associated. S2 was contacted and stated S4 previously quit and returned working at the facility 3/5/23.

The following documents were requested and are due 4/13/2023 by end of the day.

Residential Care Facility for the Elderly (RCFE):

LIC 308 Designation of Facility Responsibility
-as applicable: LIC 309 Administrative Organization
-as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
-as applicable: LIC 402 Surety Bond
LIC 500 Personnel Report
Staff Schedule for March
LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
LIC 9020 Register of Facility Clients/Residents
Copy of current Liability Insurance
Copy of current Administrator Certificate
Alternate contact information including name, telephone number, & email address.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/04/2023 10:26 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: MESSINGER CARE HOME	FACILITY NUMBER: 275202752
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

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
1 2 3 4	Based on observation, interview, & record review, 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 obstruction blocking both exits from the backyard.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Obstructions will be removed fire clearance exits. Pictures will be provided to LPA.

Type A

Section Cited

CCR

87355(e)(2)

Title 22, Division 6, Chapter 8, 87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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 caregiver in the facility who was not associated with the facility.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Caregiver will not return to the facility until they have been associated with the facility.

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	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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