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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200930
Report Date: 01/08/2024
Date Signed: 01/08/2024 03:11:44 PM

Document Has Been Signed on 01/08/2024 03:11 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:D.P. BUTLER HOMEFACILITY NUMBER:
547200930
ADMINISTRATOR:BUTLER, DIANAFACILITY TYPE:
735
ADDRESS:3500 W. VICTORTELEPHONE:
(559) 635-0224
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 4DATE:
01/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Licensee Diana ButlerTIME COMPLETED:
03:30 PM
NARRATIVE
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On 1/08/2024, Licensing Program Analyst LPA 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 by Licensee Diana Butler. The facility was observed to be at a comfortable temperature, 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 10:46 AM LPA observed expired canned foods. Fire extinguisher in the Kitchen was purchased on 08/29/2023 and was fully charged. All common areas were properly furnished and well-lit throughout. Smoke Alarm and Carbon Monoxide detector tested and operational. LPA toured 2 resident rooms and bathroom. All client bedrooms toured and observed to be adequately furnished. At 11:42 AM LPA observed window screen to be ripped in the resident’s room. Extra linens observed in the cabinet storage next to the laundry room. At 12:20 PM LPA observed cobwebs around window screens and ceilings. LPA toured the laundry; cleaning supplies and chemicals observed locked in cabinet next to laundry. The exterior tour was conducted. The backyard was observed to have sufficient seating. A covered area observed. Medication was reviewed and observed locked in the facility office. Resident records were reviewed for Admission Agreement, Physician’s Report and emergency contact information.

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 1/15/2023: 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 Licensee. 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: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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 3
Document Has Been Signed on 01/08/2024 03:11 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 01/08/2024 at 02:45 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: D.P. BUTLER HOME
FACILITY NUMBER: 547200930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 canned food was expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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Licnesee to go through all canned foods and ensure all expired items are removed.
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: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/08/2024 03:11 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 01/08/2024 at 02:45 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: D.P. BUTLER HOME
FACILITY NUMBER: 547200930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2024

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 observation, the licensee did not comply with the section cited above in 1 out of 1 bedroom observed to have cobwebs on window and ceiling which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2024
Plan of Correction
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Licensee to clean facility
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; LPA observed one resident room window screen to be ripped which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2024
Plan of Correction
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Licensee to replace window screen and submit CCLD pictures by due date.
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: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024


LIC809 (FAS) - (06/04)
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