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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206282
Report Date: 06/07/2023
Date Signed: 06/07/2023 02:52:37 PM

Document Has Been Signed on 06/07/2023 02:52 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:PIRA HOME CAREFACILITY NUMBER:
547206282
ADMINISTRATOR:PIRA, JOSE A, JR.FACILITY TYPE:
735
ADDRESS:4222 S. ROVA STTELEPHONE:
(559) 739-7030
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 4CENSUS: 4DATE:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Licensee Jose PiraTIME COMPLETED:
01:15 PM
NARRATIVE
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On 06/7/2023, 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 staff Nida Pira. Staff contacted Licensee Jose Pira, who arrived a short time later.

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 11:23 LPA observed the kitchen cabinets to have built up grease. Fire extinguisher in kitchen was last serviced on 5/16/2023 and was fully charged. Tour continued to the living room which has sufficient seating. LPA toured four resident bedrooms which were observed to be furnished with required furniture and adequate lighting. Linen supply is kept in the hallway closet. At 12:05 LPA observed bathroom fan cover to have dust buildup. Cleaning supplies and chemicals are kept locked in laundry room. Medications are kept in the Kitchen cabinet. At 12:46 LPA reviewed resident’s medication with the MARs and centrally stored list and observed the current medication bubble packs were not documented in the Centrally Stored List. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. Staff files had First Aid training. LPA observed sufficient seating under covered patio area in the back of the facility.

Deficiency is 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 6/14/2023: 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.

Exit interview was conducted. Report signed on-site; printed copy of report provided with appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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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Document Has Been Signed on 06/07/2023 02:52 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 06/07/2023 at 02:13 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: PIRA HOME CARE
FACILITY NUMBER: 547206282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 2 out of 2 when LPA observed kitchen cabinets to have built up grease and LPA observed bathroom fan cover to have dust buildup which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee asked staff to clean items during visit. Licensee agrees to schedule routine cleanings for future. POC cleared during visit.
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 Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/07/2023 02:52 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 06/07/2023 at 02:35 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: PIRA HOME CARE
FACILITY NUMBER: 547206282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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: (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.

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 1 out of 1 when LPA
observed the medication bubble packs were not documented in the Centrally Stored List. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Licensee will complete a re-training with all staff and submit documentation to Licensing of training and updated Centrally
Stored List
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 Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
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