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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200930
Report Date: 11/25/2024
Date Signed: 11/26/2024 09:27:13 AM

Document Has Been Signed on 11/26/2024 09:27 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:D.P. BUTLER HOMEFACILITY NUMBER:
547200930
ADMINISTRATOR/
DIRECTOR:		BUTLER, DIANAFACILITY TYPE:
735
ADDRESS:3500 W. VICTORTELEPHONE:
(559) 635-0224
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 4DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Licensee Diana ButlerTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 11/25/2024, 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, 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. Fire extinguisher in the Kitchen was purchased on 11/4/2024 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. LPA observed the window screen is torn on the window facing the front of the house. Extra linens observed in the cabinet storage next to the laundry room. LPA observed the ceiling of the laundry room was broken. 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. LPA observed medication was not logged in the Centrally Stored Log. Resident records were reviewed for Admission Agreement, Physician’s Report and emergency contact information.

Deficiencies are 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 12/02/2024: 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 Licensee. Report signed on-site; a copy will be provided via email including appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 11/26/2024 09:27 AM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 11/25/2024 at 02:48 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: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 one out of one window screens which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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Licensee to replace window screen and submit CCLD pictures by due date.
Type A
Section Cited
CCR
80075(k)(7)

80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the
maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, licensee did not comply with the section cited above in 4 out of 4 residents’ medications were not logged in centrally stored list which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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Licensee to ensure record of centrally stored prescription medications which is retained for at least one year and includes the following: (A) The name of the client for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E)The prescription number and the name of the issuing pharmacy. (F) Expiration date. (G) Number of refills. Licensee to submit copies of Centrally Stored list for all residents to CCL 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: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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