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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201807
Report Date: 06/21/2024
Date Signed: 06/21/2024 02:38:08 PM


Document Has Been Signed on 06/21/2024 02:38 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:SIERRA VILLAGE ASSISTED LIVINGFACILITY NUMBER:
547201807
ADMINISTRATOR:RENATA PUCKETTFACILITY TYPE:
740
ADDRESS:73 MOLENSTRAATTELEPHONE:
(559) 713-1911
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:22CENSUS: 11DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH: Administrator McKayla TurnerTIME COMPLETED:
02:45 PM
NARRATIVE
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 On 6/21/2024, 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 Administrator McKayla Turner. Administrator Renata Puckett arrived shortly after.

LPA toured the facility with the Administrator Turner. All pathways, entrances and exits were clear from obstructions. The tour started in the front room and continued dinning and kitchen. LPA observed sufficient seating in the front room. At the entry a door on the left leads to activities room and a salon area. Dining room has sufficient tables and chairs. LPA observed 4 residents playing a game in dining room. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. At 11:10 AM LPA observed the kitchen Ice machine to have black residue. Tour continued to Residents Rooms. LPA toured several bedrooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. Fire extinguisher in hallway was last serviced on 8/10/2023 and was fully charged. Linen supply is kept in the laundry room. Cleaning supplies and chemicals are kept locked in hallway closet. Medications are kept in 2 locked Med carts in the staff office. LPA observed sufficient seating under covered patio area in the back of the facility. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who is CPR certified. Medication review conducted.

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 6/28/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with appeal rights were provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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 06/21/2024 02:38 PM - It Cannot Be Edited

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: SIERRA VILLAGE ASSISTED LIVING
FACILITY NUMBER: 547201807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

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 Ice Machine was observed with black residue in and around the ice dispenser area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2024
Plan of Correction
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Licensee shall empty out ice machine, clean and sanitize and maintain routine cleaning. Pictures of the inside of the ice machine need to be submitted 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 MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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