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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209262
Report Date: 11/16/2022
Date Signed: 11/16/2022 09:27:18 PM


Document Has Been Signed on 11/16/2022 09:27 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:LOVING HEART MANORFACILITY NUMBER:
277209262
ADMINISTRATOR:ESTAMO, JUANITO JR.FACILITY TYPE:
740
ADDRESS:745 CARMELITA DRIVETELEPHONE:
(831) 758-8121
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY:6CENSUS: 6DATE:
11/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Administrator, Juanito Estamo Jr. TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA arrived and was granted entry to the facility by Administrator, Juanito Estamo Jr. . An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 07/08/2022 for a capacity of six non- ambulatory residents.

LPA Hurt observed the following:
Structure:
Facility is a two-story house with 6 resident bedrooms, 3 bathrooms, family / living room, dining area and kitchen. There is a 2-car garage attached in front of home. The resident bedrooms will accommodate residents' furnishings.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
Bedrooms #1-5 will accommodate 6 clients (one shared room)
Bathrooms:
All bathrooms have a working toilet, wash basin, and shower.
Linens and Hygiene Supplies:
Adequate supply of linens is stored in garage cabinet.
Emergency Phone Numbers, Exit Plan, and Sample Menu:
Will be posted and readily available for review in the living room.
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)
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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: LOVING HEART MANOR
FACILITY NUMBER: 277209262
VISIT DATE: 11/16/2022
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Continued from 809C...

Food Service:


LPA observed the facility does not currently have sufficient supply of 7-day non-perishable and 2 day perishable. LPA observed several containers inside kitchen, and garage refrigerator that are not labeled or dated.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems were hardwired and found operational.
Fire Extinguisher:
2 Fully charged and stored by front entrance near kitchen
Fire Clearance:
Approved on 08/22/2022
Appliances:
Electric four burner stove with oven, refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer are located in the dining area of the facility and were clean and noted to be operational.
Toxins:
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.
Water Temperature:
Tested and recorded at 122 degrees (outside of regulation)
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored near medication cabinet in dining area. Medication will be stored and locked in cabinet in dining area
Resident and Staff Files:
Records will be kept in filing cabinet in dining area
Reading Material, Games, Equipment, & Materials:
The facility has materials that commensurate with their plan of operation.

Continued onto 809C..
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
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: LOVING HEART MANOR
FACILITY NUMBER: 277209262
VISIT DATE: 11/16/2022
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Continued from 809C ..

The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Unit.

At this time, the Licensee is required to send proof of corrections for observed deficiencies before meeting all pre - licensing requirements of Title 22 division 6.

An exit interview was conducted with Administrator, Juanito Estamo Jr and a copy of this report was provided at the time of visit.
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
LIC809 (FAS) - (06/04)
Page: 2 of 3