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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 540408854
Report Date: 09/20/2024
Date Signed: 09/23/2024 10:11:25 AM

Document Has Been Signed on 09/23/2024 10:11 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:ACACIA HOMEFACILITY NUMBER:
540408854
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, DALE JR.FACILITY TYPE:
735
ADDRESS:783 ACACIA AVETELEPHONE:
(559) 638-6457
CITY:REEDLEYSTATE: CAZIP CODE:
93654
CAPACITY: 6CENSUS: 6DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:47 AM
MET WITH:Licensee, Lupe MartinezTIME VISIT/
INSPECTION COMPLETED:
05:14 PM
NARRATIVE
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On 9/20/2024 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Licensee, Lupe Martinez, Administrator, Dale Martinez Jr. and Program Manager, Krystyn Cuevas. LPA explained reason for visit and was permitted entry into the facility.

Residents not present during todays visit. LPA toured the facility inside and out. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 5/22/24. Last fire drill on 8/9/24. Water temperature measured 109.2 degrees F in restroom #1. Linen supplies are kept in linen closets. Sharps and medications were located in locked cabinets. LPA observed sufficient seating under covered patio areas.

The following issues were observed during todays visit: Front door screen torn and in need of repair. Water hose observed in walkway to right of the facility. Small step observed from living room to activity room. Possible tripping hazard. Left side fence leaning and in need of repair. Spider webs observed in back yard in need of cleaning. Right side gate not self latching. Chemicals observed in room off kitchen unlocked and accessible to residents in care. Trash cans observed to be open and not closing properly with trash inside. 3 of 3 resident rooms observed without all required items. (Rm 1- missing 1 lamp. Rm 2- missing night stand (resident has standing shelf), 1 chair, 2 lamps, Rm 3-missing 1 lamp, 2 chairs and 1 night stand). 1 of 6 residents with a non-ambulatory status reported on physicians report. CONT....
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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 4
Document Has Been Signed on 09/23/2024 10:11 AM - It Cannot Be Edited


Created By: Mary Garza On 09/20/2024 at 04:29 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: ACACIA HOME
FACILITY NUMBER: 540408854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 1 of 6 residents physicians report identified them with a non-ambulatory status. Licensee is licensed for 6 ambulatory only. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Licensee to provide CCL a plan of correction in writting.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/23/2024 10:11 AM - It Cannot Be Edited


Created By: Mary Garza On 09/20/2024 at 04:29 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: ACACIA HOME
FACILITY NUMBER: 540408854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that front door screen is torn and in need of repair. Water hose observed in walkway to right of the facility. Small step observed from living room to activity room. Possible tripping hazard. Left side fence leaning and in need of repair. Spider webs observed in back yard in need of cleaning. Right side gate not self latching. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee stated corrections will be made for the deficiencies found during todays visit. Proof of correction will be sent to CCL by POC in the form of pictures.
Type B
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 LPA observations, the licensee did not comply with the section cited above in that chemicals were observed in room off kitchen, unlocked and accessible to residents in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee stated that lock will be place on cabinets. Proof of correction will be submitted to CCL by POC date in the form of pictures.
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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


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: ACACIA HOME
FACILITY NUMBER: 540408854
VISIT DATE: 09/20/2024
NARRATIVE
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Facility does not have copy of fire clearance posted. Facility does not have a electronic device for client use. Freezer in wash room in need of defrosting. Disaster Plan in need of detailed answers.

LPA requested the following documents to be submitted to CCL by 9/27/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Deficiencies cited per Title 22 and TV's provided. Exit interview completed with Licensee, Administrator and Program Manager. A copy of this report, deficiencies, TFacility does not have copy of fire clearance. Facility does not have a device for client use. Freezer in wash room in need of defrosting. Disaster Plan in need of detailed answers.

LPA requested the following documents to be submitted to CCL by 9/27/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview completed with Licensee, Administrator and Program Manager. A copy of this report was given. TV's and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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