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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202320
Report Date: 08/08/2024
Date Signed: 08/09/2024 08:58:35 AM

Document Has Been Signed on 08/09/2024 08:58 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:BLUE RIVERFACILITY NUMBER:
355202320
ADMINISTRATOR/
DIRECTOR:		COOK, DEANEFACILITY TYPE:
735
ADDRESS:245 DAFFODIL DR.TELEPHONE:
(831) 638-1040
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 12CENSUS: 12DATE:
08/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:33 AM
MET WITH:Supervisor Luz Lopez SanchezTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 08/08/2024 Licensing Program Analyst (LPA) V Gorban visited the facility stated above to conduct case management. This visit resulted in regard to incident report Licensing office received for C1 on 07/15/2024

During this visit LPA conducted safety check by touring the facility and observing clients in care. Staff and client's files were reviewed for required and updated contact information. Based on clients file review and staff interview records for C1 and C2 were not up to date.

The deficiency issued on attached LIC 809-D

Exit interview conducted, report signed and copy of this report with appeal rights provided to the facility staff Luz Lopez Sanchez.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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 08/09/2024 08:58 AM - It Cannot Be Edited


Created By: Vadim Gorban On 08/08/2024 at 11:35 AM
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: BLUE RIVER
FACILITY NUMBER: 355202320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2024
Section Cited
CCR
85068.4(e)

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85068.4 Acceptance and Retention Limitations. (e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)]. This requirement was not met as evidenced by:
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The facility staff Offered shcedule a docgtrs appointemt with client PCP. Staff will notfy LPA of schedule apointmnent time by email and once clinets physicianreport updated, staf will provide a copy to LPA by email by POC date.
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During file review and interview was observed that physician report for C1 and C2, who is 60 years of age or older was not updated which posses potential health and safety of persons 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 Chan
LICENSING EVALUATOR NAME:Vadim Gorban
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
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