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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 540405565
Report Date: 02/24/2024
Date Signed: 02/24/2024 03:47:54 PM

Document Has Been Signed on 02/24/2024 03:47 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:SUE'S CARE FACILITYFACILITY NUMBER:
540405565
ADMINISTRATOR:TINA ALAFAFACILITY TYPE:
735
ADDRESS:1616 CASTLEVIEWTELEPHONE:
(559) 739-0712
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 6CENSUS: 4DATE:
02/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:House Manager/ Designee Connie PowellTIME COMPLETED:
04:00 PM
NARRATIVE
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On 02/24/2024, Licensing Program Analyst LPA(s) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility House Manager / Designee Connie Powell (HM). Administrator was contacted via phone and informed LPA to conduct annual with HM.

LPA conducted tour with Staff. The facility was observed to be at a comfortable temperature, clean, in good repair, with no passageway obstructions or fire hazards. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. At 10:20 AM LPA observed milk and other food products past the best by date. LPA also observed tomatoes that were rotten. Fire extinguisher in the Kitchen was last serviced on 01/29/2024 and was fully charged. All common areas were properly furnished and well-lit throughout. First Aid is kept in kitchen cabinet. LPA observed sharps kept in locked kitchen cabinet. The tour continued to laundry area adjacent to kitchen which leads into the garage. Chemicals are kept in locked cabinet in garage. At 11:23 PM LPA observed unlocked laundry detergent in the garage. Smoke Alarm and Carbon Monoxide detector tested and operational. LPA observed medication locked in hallway closet. LPA viewed the staff bedroom downstairs. The exterior tour was conducted. The backyard was observed to have sufficient area for rest and recreational.

LPA toured 3 resident rooms upstairs. LPA observed cleaning supplies accessible to residents. All client bedrooms toured and observed to be adequately furnished. Extra linens observed in the hallway cabinets. Medication was reviewed. Staff records were reviewed for good health and training, all clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. Last fire drill completed on 01/1/2024. At 1:12 PM During medication audit LPA discovered medication count to have a extra pill that may not have been given to resident in care.

Continued on 809C...
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2024
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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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: SUE'S CARE FACILITY
FACILITY NUMBER: 540405565
VISIT DATE: 02/24/2024
NARRATIVE
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Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPAs is requesting the following documents be submitted to the Fresno CCL office by 3/01/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Staff. Report signed on-site, a printed copy was provided including appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2024 03:47 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/24/2024 at 03:13 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: SUE'S CARE FACILITY
FACILITY NUMBER: 540405565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 2 out of 2 areas; laundry soap observed in the garage and cleaning supplies upstairs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2024
Plan of Correction
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Staff immediately removed and locked products. Licensee to ensure chemicals and cleaning supplies are locked at all times and not accessible to residents in care. **Cleared during visit**
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 3 out of 3 items observed past best by date and produce observed that was rotten which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2024
Plan of Correction
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Staff immediately discarded items. Licensee to ensure food is looked at timely and removed if expired or spoiled. **Cleared during visit**
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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/24/2024 03:47 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 02/24/2024 at 03:13 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: SUE'S CARE FACILITY
FACILITY NUMBER: 540405565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 residents medication count reviled medication may not have been administrated per Centrally Stored Medication and Destruction Record (CSMDR) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2024
Plan of Correction
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Licensee to submit a statement of plan by due date to conduct a medication audit and complete in service training and submit records of both by 3/8/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2024


LIC809 (FAS) - (06/04)
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