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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202421
Report Date: 12/15/2023
Date Signed: 12/15/2023 01:35:38 PM

Document Has Been Signed on 12/15/2023 01:35 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:BRYANT-LITTLE HOME 2FACILITY NUMBER:
547202421
ADMINISTRATOR:BRYANT, JANICEFACILITY TYPE:
735
ADDRESS:2733 WEST COUNTRY LANETELEPHONE:
(559) 802-3589
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 4CENSUS: 4DATE:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:House Manager Damon BlyTIME COMPLETED:
01:45 PM
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On 12/15/2023, 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 House Manager Damon Bly.

LPA conducted tour with Staff. The facility was observed to be at a comfortable temperature, clean, 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. Fire extinguisher in the Kitchen was last serviced on 09/7/2023 and was fully charged. All common areas were properly furnished and well-lit throughout. Medications, First Aid, and Sharp items locked in the Staff office closet. Smoke Alarm and Carbon Monoxide detector tested and operational. LPA toured 4 resident rooms and an office. All client bedrooms toured and observed to be adequately furnished. At 9:46 AM LPA observed window screens to be bent/broken. Extra linens observed in the hallway closet. LPA tested the water temperature in the bathroom at 113.5 degrees. LPA toured laundry area which appeared clean. Cleaning supplies and chemicals observed locked in cabinet next to laundry. The exterior tour was conducted. The backyard was observed to have sufficient seating. The pool was gated and locked. Sufficient covered area for recreational use. The backyard gate was self-latching and self-closing. Medication was reviewed. Staff records were reviewed for good health and training, all clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. Last fire drill completed on 12/5/2023. At 11:45 AM LPA observed during record review the resident funds did not match the amount shown on the ledgers

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

Continued to Next Page
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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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: BRYANT-LITTLE HOME 2
FACILITY NUMBER: 547202421
VISIT DATE: 12/15/2023
NARRATIVE
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LPA is requesting the following documents be submitted to the Fresno CCL office by 12/22/2023: 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: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2023 01:35 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 12/15/2023 at 01:22 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: BRYANT-LITTLE HOME 2
FACILITY NUMBER: 547202421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

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 3 out of 3 window screens observed bent/broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Licnesee to replace broken blinds 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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4
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: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2023 01:35 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 12/15/2023 at 01:25 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: BRYANT-LITTLE HOME 2
FACILITY NUMBER: 547202421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80026(h)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 4 resident's cash resources were audited. One of the resident funds did not match the amount shown on the ledger which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licnesee to update records to reflect accurate amount based on receipts/and funds and ensure future records are accurate.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
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