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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200150
Report Date: 05/02/2024
Date Signed: 05/02/2024 01:51:10 PM

Document Has Been Signed on 05/02/2024 01:51 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:DIAZ FAMILY CARE HOMEFACILITY NUMBER:
547200150
ADMINISTRATOR/
DIRECTOR:		DIAZ, DIANNA & ANTONIOFACILITY TYPE:
735
ADDRESS:1603 S. PEPPERTREE CT.TELEPHONE:
(559) 635-4360
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 4DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator Vanessa GardunoTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 5/02/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA was allowed entry by Administrator Vanessa Garduno.

The facility was observed to be at a comfortable temperature, clean, in good repair, with no passageway obstructions or fire hazards. Sharp items and medications are locked in hallway closet. Cleaning supplies are locked in the entry closet. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the kitchen was last serviced on 12/14/2023 and was fully charged. Common areas were properly furnished and well-lit throughout. Smoke alarm and carbon monoxide tested and operational. LPA toured 3 bedrooms with one shared bedroom and two single occupants. LPA observed 1 live in staff bedroom. All clients’ bedroom toured and observed to be adequately furnished and lit and restrooms observed to be clean, odor free and functioning at time of visit. LPA observed in the shared bedroom the window screen was ripped. The exterior tour was conducted. Backyard observed to have sufficient seating. Backyard gate was self-latching and self-closing. Medication was reviewed. Staff records were reviewed for good health and infection control training. All clients’ records reviewed to have updated emergency contact information. Last fire drill: 04/01/24.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22,
Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 5/09/2024: 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 (LIC610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a printed copy was provided with appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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 05/02/2024 01:51 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 05/02/2024 at 01:33 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: DIAZ FAMILY CARE HOME
FACILITY NUMBER: 547200150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 1 out of 1 window screen was observed torn which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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Licensee to repair or replace window screen and submit pictures to CCLD by due date.
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:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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