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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202781
Report Date: 05/15/2024
Date Signed: 05/15/2024 10:45:14 AM

Document Has Been Signed on 05/15/2024 10:45 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:BAUTISTA HOMEFACILITY NUMBER:
355202781
ADMINISTRATOR/
DIRECTOR:		MITCHELL GUEVARAFACILITY TYPE:
737
ADDRESS:777 OLYMPIATELEPHONE:
(831) 818-7981
CITY:SAN JAUN BAUTISTASTATE: CAZIP CODE:
95045
CAPACITY: 4CENSUS: 4DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Mitchell Guevara - AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
NARRATIVE
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On 5/15/2024, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a case management inspection. LPA met with Administrator Mitchell Guevara and announced the purpose of the inspection. LPA toured the facility inside and outside.

This inspection was conducted to follow up on an incident which facility staff reported to the department on 4/29/2024. On 4/29/2024, around 8:00 pm, staff realized that Resident 1(R1) had not received one of his morning medications from that day. R1's primary care provider was notified and no adverse effects were observed.

See attached LIC-809D for a Type-B Citation issued in accordance with California Code of Regulations, Title 22, Division 6, Chapter 1. A copy of the report and appeal rights were provided to the licensee.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 05/15/2024 10:45 AM - It Cannot Be Edited


Created By: David Ayers On 05/15/2024 at 10:14 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: BAUTISTA HOME
FACILITY NUMBER: 355202781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
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Administrator agreed to provide CCLD with records of medication retraining for staff members involved in the incident by POC due date.
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Based on records review and interview, the licensee failed to ensure that one out of four residents received their prescribed medications on the morning of 4/29/2024, which presented a potential risk to the health and safety of clients 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:David Ayers
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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