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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208766
Report Date: 08/11/2022
Date Signed: 08/30/2022 08:46:10 AM

Document Has Been Signed on 08/30/2022 08:46 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SEQUOIA ADULT ACTIVITY CENTERFACILITY NUMBER:
547208766
ADMINISTRATOR:CONLEY, LORRIEFACILITY TYPE:
775
ADDRESS:1329 N ALTA AVETELEPHONE:
(559) 315-5351
CITY:DINUBASTATE: CAZIP CODE:
93618
CAPACITY: 30CENSUS: 18DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Direct Care Staff, Melinda ConleyTIME COMPLETED:
01:29 PM
NARRATIVE
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On 8/11/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced infection control/annual visit. LPA met with Care Staff, Melinda Conley. LPA contacted Administrator, Lorrie Conley who stated they were unavailable at the time. Administrator gave permission to complete visit with Melinda Conley. LPA completed a health and safety check on clients in care and toured the facility. Facility was toured inside and out.

LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. LPA was not COVID pre-screened at time of entry.

Infection Control Plan was submitted. Infection control procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

Required postings of signs to include hand washing, and physical distancing were observed throughout the facility. 3 of 3 staff observed without face coverings. Covered trash bins were observed. A supply of PPE was not observed. Administrator to provide additional PPE for staff. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying observed.

Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices were not found to be in compliance. TA's given on todays inspection for infection control.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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 08/30/2022 08:46 AM - It Cannot Be Edited


Created By: Mary Garza On 08/11/2022 at 01:09 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: SEQUOIA ADULT ACTIVITY CENTER
FACILITY NUMBER: 547208766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site 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 LPA observation, the licensee did not comply with the section cited above in tools, chemicals, unlocked gates leading to various items and shaving razor are accessible. LPA observed refrigerator with repackaged food and not dated, clutter throught the facility inside and out and an unlocked storage unit accessible to clients in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2022
Plan of Correction
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Licensee to provide a plan of correction including timeline in writting showing steps that will be taken to get the facility in compliance. Once written plan is provided Licensee to update CCL of progress no later than 9/9/2022.
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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/30/2022 08:46 AM - It Cannot Be Edited


Created By: Mary Garza On 08/11/2022 at 01:43 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: SEQUOIA ADULT ACTIVITY CENTER
FACILITY NUMBER: 547208766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(e)(1)
(e) All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure...(1) Fences shall be... and locked while the pool is not in use.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in 2 of 3 pool gates were opened and unlocked and accessible to two clients in close proximity without supervison. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Staff immediately closed the gates and clients were asked to go inside the facility. Licensee to provide training to all staff on regulations. A sign in sheet and training material will be provided to CCL by POC date.
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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
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