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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206282
Report Date: 06/28/2024
Date Signed: 06/28/2024 04:21:48 PM

Document Has Been Signed on 06/28/2024 04:21 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/
DIRECTOR:		PIRA, JOSE A, JR.FACILITY TYPE:
735
ADDRESS:4222 S. ROVA STTELEPHONE:
(559) 739-7030
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 4CENSUS: 4DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Licensee Jose PiraTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 06/28/2024, 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 staff. 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. Fire extinguisher in kitchen was last serviced on 6/1/2024 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. All four residents were present; returned from day program within the hour. LPA observed 2 out of 4 residents with full bed rails. Linen supply is kept in the hallway closet. Cleaning supplies and chemicals are kept locked in laundry room. Medications are kept in the Kitchen cabinet. Carbon Monoxide and smoke alarm detector were observed operational. Fire drill conducted June 2024. LPA reviewed resident’s medication with the MARs and centrally stored. 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 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 7/05/2024: 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: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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 06/28/2024 04:21 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 06/28/2024 at 03:56 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: 06/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(8)(E)1
Personal Rights
1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 4 residents observed with full bed rails with no physicans order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2024
Plan of Correction
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Licensee to submit a plan of intent to get a physician’s order for full bed rails. In the meantime, rails will be adjusted to half rails. Once documentation is received a copy needs to be submitted to CCLD
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: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024


LIC809 (FAS) - (06/04)
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