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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202838
Report Date: 11/16/2022
Date Signed: 11/22/2022 08:55:58 AM

Document Has Been Signed on 11/22/2022 08:55 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:HARTNELL HOME TWOFACILITY NUMBER:
275202838
ADMINISTRATOR:BINARAO, PATRICKFACILITY TYPE:
735
ADDRESS:620 COLLEGE DR.TELEPHONE:
(831) 753-7630
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY: 6CENSUS: 4DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:House Manager, Excalibur HolderTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with House Manager Excalibur Holder, Continual Administrator's Certification for Patrick Binarao expires 02/05/2024. There are currently 4 clients living in this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector. First Aid kit is on site and complete. LPA Hurt confirmed staff present is background cleared. LPA Hurt confirmed staff present has a COVID 19 vaccine card or exemption on file.

LPA Hurt observed the facility staff room unlocked, and several chemicals were in the bathroom accessible to residents. LPA Hurt observed the metal window screen for window located inside the kitchen to be bent and not covering entire window. LPA Hurt observed a "make shift" office between garage and kitchen not listed on facility sketch. LPA Hurt observed the facility water to be hotter than 120 degrees.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with House Manager Excalibur Holder and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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 11/22/2022 08:55 AM - It Cannot Be Edited


Created By: Sarah Hurt On 11/16/2022 at 02:52 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: HARTNELL HOME TWO
FACILITY NUMBER: 275202838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in LPA observed staff bedroom door unlocked leaving chemicals accesible to residents in staff bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2022
Plan of Correction
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Administrator will conduct staff training on hazardous chemicals and submit proof to LPA by 11/30/2022 POC date.
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:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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