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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294306
Report Date: 11/16/2022
Date Signed: 11/16/2022 09:28:09 PM


Document Has Been Signed on 11/16/2022 09:28 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:QUEEN OF ANGELS II RCFEFACILITY NUMBER:
275294306
ADMINISTRATOR:ANDOY, MERZAFACILITY TYPE:
740
ADDRESS:745 CARMELITA DRIVETELEPHONE:
(831) 758-8121
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:6CENSUS: 6DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Administrator, Juanito Estamo Jr.TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit to the facility for purpose of a Case Management - Deficincies visit. LPA Hurt met with Administrator, Juanito Estamo Jr. and explained the purpose for today's visit.

LPA Hurt toured the facility including the kitchen, garage, dining area, and resident bedrooms.

LPA Hurt observed a small Gatorade bottle filled with laundry detergent, and another large unlabeled bottle with laundry detergent unlocked and accessible to dementia residents. LPA Hurt measured the facility resident bathroom in the hallway water temperature to be 122 degrees. LPA Hurt observed the facility refrigerator in the garage, and kitchen area to have several containers of unmarked, unlabeled food. LPA Hurt observed the facility does not have the required sufficient food supply of 7 days non - perishable, and 2 days perishable.

The following Deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Administrator, Juanito Estamo Jr. 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: 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 11/16/2022 09:28 PM - 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: QUEEN OF ANGELS II RCFE
FACILITY NUMBER: 275294306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited

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 Care of Persons with Dementia 87705 (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. The following requirement has not been met as evidenced by:
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LPA Hurt observed two unmarked bottles with laundry soap unlocked and accessible to dementia residents which poses an immediate health, safey, or personal rights risk to residents in care.
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Type B
11/30/2022
Section Cited

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Maintenance and Operation 87303 (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). The following requirement has not been met as evidenced by:
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LPA Hurt observed two facility sinks out of four (kitchen and resident bathroom in hallway) to measure above 120 degrees which poses a potentiol health, safety, or personal rights risk to residents in care.
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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 ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
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)
Page: 2 of 2