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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203489
Report Date: 02/21/2023
Date Signed: 02/21/2023 11:39:19 AM

Document Has Been Signed on 02/21/2023 11:39 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:AGUILAR HOMEFACILITY NUMBER:
547203489
ADMINISTRATOR:AGUILAR, SYLVIA R.FACILITY TYPE:
735
ADDRESS:17353 ROAD 320TELEPHONE:
(559) 784-5157
CITY:SPRINGVILLESTATE: CAZIP CODE:
93265
CAPACITY: 4CENSUS: 3DATE:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:John and Sylvia Aguilar, LicenseesTIME COMPLETED:
12:00 PM
NARRATIVE
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On 2/21/23 at 9:45 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. LPA met with Licensees (LIC) John and Sylvia Aguilar.

LPA toured inside and outside of facility. No fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bedrooms were checked. Two residents share one room. LPA checked residents’ medications. Cleaning and PPE supplies were checked.

The following deficiency was observed:
1. LPA observed sharps (knives, scissors, sharp kitchen tools) accessible on kitchen counter and in drawer; bottle of bleach accessible on kitchen floor; multiple cleaner bottles accessible in cabinet under kitchen sink and north hall bathroom; and garden tools (shovels, shears, metal rake, pike axe, cultivator, saw) observed accessible in garage and in back patio.

The following updated forms to be sent to CCL within 2 weeks:
-LIC500, LIC400, LIC402, LIC610D (new revision), LIC9020, LIC308

Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights was given to Licensee John Aguilar, whose signature confirms receipt of this report.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
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 02/21/2023 11:39 AM - It Cannot Be Edited


Created By: Malia Thao On 02/21/2023 at 11:17 AM
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: AGUILAR HOME
FACILITY NUMBER: 547203489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. LPA observed sharps (knives, scissors, sharp kitchen tools) accessible on kitchen counter and in drawer; bottle of bleach accessible on kitchen floor; multiple cleaner bottles accessible in cabinet under kitchen sink and north hall bathroom; and garden tools (shovels, shears, metal rake, pike axe, cultivator, saw) observed accessible in garage and in back patio, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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Licensee immediately locked sharps in office, removed bottle of bleach to locked storage unit in garage, removed all garden tools to locked shop building in backyard. POC cleared during inspection.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023


LIC809 (FAS) - (06/04)
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