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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208819
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:45:16 PM

Document Has Been Signed on 10/03/2023 03:45 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:PATRIOT IN THE WESTFACILITY NUMBER:
547208819
ADMINISTRATOR:DARLENE HATHCOCKFACILITY TYPE:
735
ADDRESS:3702 N SALLEE STREETTELEPHONE:
(559) 733-3631
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 3DATE:
10/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Darlene Hathcock, AdministratorTIME COMPLETED:
04:00 PM
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On 10/3/23 at 2:16 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management inspection - incident inspection. LPA explained reason for inspection and met with Administrator (ADM) Darlene Hathcock.

On 9/15/23, CCL received a Special Incident Report (SIR) from the facility reporting S1 did not administer R1's Med1 on 9/14/23 for the 2AM dose.

LPA conducted interview and reviewed records. ADM states the missed dose was discovered when ADM arrived in the morning and saw that Med1 was not signed for. ADM states S1 reported R1 was asleep at the time and S1 forgot. Immediately upon discovery, ADM notified supervisor, behaviorist, and contacted R1's PCP for an appointment to address the missed dose. ADM was able to conduct a tele health appointment with R1's nurse practitioner at the lunch hour. R1 did not experience any adverse reactions. S1 has been removed from self-administration medication assistance for all residents in the facility until S1 has been retrained.

A deficiency is being cited based on LPA interview conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with Administrator Darlene Hathcock, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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 10/03/2023 03:45 PM - It Cannot Be Edited


Created By: Malia Thao On 10/03/2023 at 03:27 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: PATRIOT IN THE WEST
FACILITY NUMBER: 547208819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2023
Section Cited
CCR
80075(b)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
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Administrator will submit proof of medication administration training for S1 to CCL by POC due date.
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On 9/14/23, S1 did not administer R1's Med1 at the 2AM dose due to forgetting to administer, which poses an immediate health and/or personal rights risk to residents in care.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
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