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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206636
Report Date: 11/13/2024
Date Signed: 11/13/2024 02:02:53 PM

Document Has Been Signed on 11/13/2024 02:02 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 CARE HOME 3FACILITY NUMBER:
547206636
ADMINISTRATOR/
DIRECTOR:		GARDUNO, VANESSAFACILITY TYPE:
735
ADDRESS:2313 S. JACQUES STTELEPHONE:
(559) 738-1072
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 6DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Vanessa GardunoTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 11/13/2024, 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 Administrator Vanessa Garduno.

The facility was observed to be at a comfortable temperature, clean, in good repair, with no passageway obstructions or fire hazards. Facility has 2 levels with a storage room and common areas downstairs; Staff and residents bedrooms upstairs. LPA and Administrator began the tour in the backyard. LPA observed sufficient seating under covered patio area in the back of the facility. Pool was observed gated and locked. Living room and facility kitchen toured. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Closet under stairs was observed to be locked with sharps, medications and files. Tour continued to the den which has sufficient seating. Den has a locked closet that was observed to have chemicals. Fire extinguisher in dining area was last serviced on 12/14/2023 and was fully charged. Carbon monoxide and smoke alarm detectors installed and operational. LPA toured 4 single occupancy rooms and one shared bedroom which were observed to be furnished with required furniture and adequate lighting. LPA viewed live in staff bedroom. Linen supply is kept in the hallway cabinets upstairs next to laundry room. Additional cleaning and chemicals observed locked in laundry room. Last fire drill was conducted on 11/7/2024. LPA reviewed resident’s medication with the MARs and centrally stored list. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. LPA observed 1 out of 6 residents had the incorrect medical assessment form. Staff files were reviewed for good health. Staff files had First Aid training.

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

Continued to 809-C...
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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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 CARE HOME 3
FACILITY NUMBER: 547206636
VISIT DATE: 11/13/2024
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LPA is requesting the following documents be submitted to the Fresno CCL office by 11/20/2024: 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 with administrator. 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: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2024 02:02 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 11/13/2024 at 12:30 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 CARE HOME 3
FACILITY NUMBER: 547206636

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

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 1 out of 1 resident's medical assessments needs to be completed on LIC602A which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Administrator agrees to schedule an appointment by due date and submit new LIC602A when completed.
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: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


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