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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208880
Report Date: 12/14/2022
Date Signed: 12/14/2022 08:01:23 PM

Document Has Been Signed on 12/14/2022 08:01 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:PEOPLE'S CARE MARLINFACILITY NUMBER:
547208880
ADMINISTRATOR:BUTLER, SHARONFACILITY TYPE:
735
ADDRESS:12744 MARLIN AVETELEPHONE:
(559) 372-8827
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
12/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Patricia Gomez, AdministratorTIME COMPLETED:
06:30 PM
NARRATIVE
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On 12/14/22 at 3:00 PM, Licensing Program Analyst (LPA) Malia Thao conducted a case management - deficiencies inspection. LPA met with Administrator (ADM) Patricia Gomez.

During the complaint inspection for complaint #24-AS-20221207161724, LPA found the following deficiency:

1. S1 did not have a completed transfer of criminal record clearance. S1 has been working in the facility since October 2022 and was presently working in the facility.

Deficiencies are being cited based on interviews and records review conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days, for a total of $500. See LIC421BG for more details.

An exit interview was conducted and Plan of Correction was reviewed and developed with the Administrator. Due to technical difficulties, LPA emailed today's report to Administrator. Administrator provided current email for receipt of reports.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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 12/14/2022 08:01 PM - It Cannot Be Edited


Created By: Malia Thao On 12/14/2022 at 05:50 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: PEOPLE'S CARE MARLIN
FACILITY NUMBER: 547208880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
Section Cited
CCR
80019(e)(2)

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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or
This requirement is not met as evidenced by:
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Administrator completed transfer of criminal record clearance via Guardian website and provided proof of transfer to LPA. POC cleared during inspection.
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S1 did not have a completed transfer of criminal record clearance. S1 has been working in the facility since October 2022 and was presently working in the facility, which poses an immediate health, safety, 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: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022


LIC809 (FAS) - (06/04)
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