547204148-8-4-2023-24-AS-KKAR-CUDTZ7-20230804150953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547204148
Report Date: 08/04/2023
Date Signed: 08/04/2023 03:11:07 PM

Document Has Been Signed on 08/04/2023 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:	DIAZ OAK VIEW HOME		FACILITY NUMBER:	547204148
ADMINISTRATOR:	DIAZ, MARIETTA		FACILITY TYPE:	735
ADDRESS:	144 W. OAK VIEW DR		TELEPHONE:	(559) 741-1002
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY: 6		CENSUS: 4	DATE:	08/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Licensee Marietta Diaz		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/4/2023, 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 Licensee Marietta Diaz. Tour was conducted with Licensee Marietta Diaz and Avelina Sanlitan, designated representative. All pathways, entrances and exits were clear from obstructions. LPA and staff began the tour at the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. At 10:38 AM LPA observed Fire extinguisher in the Kitchen to be expired with a service date of 7/27/2022. Tour continued to laundry room which has locked chemicals and cleaning supplies. At 11:09 AM LPA observed the facility front load washer to have what appeared like possible mold or mildew on the washer’s front plastic plate. LPA observed a staff room, storage area and staff bathroom. Tour continued to the living room which has sufficient seating and office area. LPA toured two more staff rooms with bathroom in hallway. Medications, PPE supplies, and files are locked in hallway closet. LPA toured two shared resident bedrooms which were observed to be furnished with required furniture and adequate lighting. Bedroom share a bathroom. Linen and hygiene supply is kept in the hallway closet. Carbon monoxide and smoke alarm detectors installed and operational. LPA reviewed resident’s medication and Centrally Stored List for all residents. At 12:46 PM LPA observed residents’ files to be missing Needs and services plan. LPA reviewed Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health, First Aid training. LPA observed sufficient seating under covered patio area in the back of the facility. Backyard gate was self-latching and self-closing. 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: 08/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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: DIAZ OAK VIEW HOME	FACILITY NUMBER: 547204148
	VISIT DATE: 08/04/2023

NARRATIVE

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LPA is requesting the following documents be submitted to the Fresno CCL office by 6/14/2023: 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. Deficiencies and corrections reviewed with Licensee. Report signed on-site; printed copy provided including appeal rights.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2023 03:11 PM - It Cannot Be Edited

Created By: Kamaldeep Kaur On 08/04/2023 at 02:32 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: DIAZ OAK VIEW HOME	FACILITY NUMBER: 547204148
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.2(b)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 4 persons Residents files did not have Needs and Services which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	Licensee to ensure all residents have a Needs and services plan and ensure prior to accepting new residents a Needs and services plan is completed and updated as necessary.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: 08/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

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