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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202839
Report Date: 02/21/2023
Date Signed: 02/21/2023 03:42:54 PM

Document Has Been Signed on 02/21/2023 03:42 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:HARTNELL HOME ONEFACILITY NUMBER:
275202839
ADMINISTRATOR:BINARAO, PATRICKFACILITY TYPE:
735
ADDRESS:618 HARTNELL ST.TELEPHONE:
(415) 336-5277
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY: 6CENSUS: 5DATE:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Facility staff, Ignedio Chavez TIME COMPLETED:
04:00 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 facility staff Ignedio Chavez, 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, common areas, medication storage, kitchen, garage and outdoor areas. 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 observed two dressers in resident rooms to have broken drawers. LPA Hurt observed the facility resident bathroom door to be broken, rusted, and rotting near the bottom door frame. LPA Hurt observed the bathroom fan to make a very loud sound. LPA Hurt observed a cabinet located in the facility kitchen labeled "staff" to be unlocked and accessible to residents. LPA Hurt observed Tylenol, and cough medicine inside the unlocked cabinet. LPA Hurt observed a refrigerator in the facility garage labeled "staff refrigerator" that did contain items used to cook for facility residents. LPA Hurt observed the refrigerator to have food in containers with no date or label. LPA Hurt observed "antacid liquid" medication inside the refrigerator. LPA observed linen storage area in hallway with no doors, and a sheet covering in place of doors.

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 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 facility staff Ignedio Chavez and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
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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Document Has Been Signed on 02/21/2023 03:42 PM - It Cannot Be Edited


Created By: Sarah Hurt On 02/21/2023 at 02:47 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 ONE
FACILITY NUMBER: 275202839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)

80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:

(1) Medication 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, the licensee did not comply with the section cited above in the outside refrigerator located in facility garage contained "antacid liquid" medication, a cabinet inside the facility kitchen contained tylenol, and cough syrup, both aeras unlocked and accesible to facility residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2023
Plan of Correction
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Administrator will conduct training on medication storage and submit proof to LPA by 02/22/2023 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: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/21/2023 03:42 PM - It Cannot Be Edited


Created By: Sarah Hurt On 02/21/2023 at 03:14 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 ONE
FACILITY NUMBER: 275202839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.


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 in two resident bedrooms have broken dresser drawers, the resident hallway bathroom has rust, and broken wood around bottom of the doorway, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2023
Plan of Correction
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Administrator will fix dressers, and bathroom door area and submit proof to LPA by POC date of 03/01/2023.
Type B
Section Cited
CCR
80076(a)

80076 Food Services

(a) In facilities providing meals to clients, the following shall apply:


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 in LPA observed the facility garage refrigerator contains several food items with no date or expiration, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2023
Plan of Correction
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Administrator will conduct training on food service requirements and submit proof to LPA by POC date of 03/08/2023.
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 Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023


LIC809 (FAS) - (06/04)
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