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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208880
Report Date: 07/28/2023
Date Signed: 07/28/2023 04:43:09 PM

Document Has Been Signed on 07/28/2023 04:43 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:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Marrissa Galaz, DSP IITIME COMPLETED:
05:00 PM
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On 7/28/23 at 3:10 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. LPA met with staff DSP II Marrissa Galaz. Administrator Tara Allen was available by telephone and authorized Marrissa to sign today's report. Two staff and four residents were present during the inspection.

LPA toured the facility and did not observe any obstructions. Facility set at a comfortable temperature. Bedrooms observed with sufficient furniture and lighting. Hall bathroom hot water measured at 113.4 degrees F. Chemicals observed stored in locked hall closet. Medication centrally stored in locked cabinet in large living area. Sharps observed in lock box in locked cabinet in laundry room. Food supply observed sufficient. Smoke and carbon monoxide detector tested and operational.

The following deficiencies were observed:
1. Cleaning spray bottles and can of powder cleaner observed accessible in cabinet under kitchen sink.

Deficiencies are being cited based on observations conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Administrator via telephone.

The following updated forms are to be submitted to CCL within 2 weeks:

LIC500, LIC9020, LIC308, LIC400, LIC402, LIC610D (new revision)

***Due to time constraints, LPA will return at a later date to conduct an Annual Continuation for completion of the Inspection Tool.***

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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 07/28/2023 04:43 PM - It Cannot Be Edited


Created By: Malia Thao On 07/28/2023 at 04:37 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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Cleaning spray bottles and can of powder cleaner observed accessible in cabinet under kitchen sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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Facility staff immediately removed cleaning spray bottles and can of powder cleaner to the designated closet where chemicals are kept. POC cleared during the inspection.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
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