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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209005
Report Date: 11/22/2022
Date Signed: 11/22/2022 01:14:27 PM

Document Has Been Signed on 11/22/2022 01:14 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:MARTINEZ RESIDENCEFACILITY NUMBER:
547209005
ADMINISTRATOR:MARTINEZ, EESAENGFACILITY TYPE:
735
ADDRESS:3527 W OAKRIDGE AVETELEPHONE:
(559) 786-1819
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Eesaeng Martinez, Licensee/AdministratorTIME COMPLETED:
01:35 PM
NARRATIVE
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On 11/22/22 at 9:05 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. Licensee/Administrator (LIC) Eesaeng Martinez arrived a short time later.

LPA toured inside and outside of the facility, and did not observe any obstructions. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sink. Bedrooms were checked. LPA checked residents’ medications. Cleaning and PPE supplies were checked. Staff files checked for health assessments.

LPA observed the following deficiencies:
1. LPA observed fire extinguisher in kitchen area was last serviced 9/16/21.
2. Exterior fire exit gate observed sticking and not opening/closing with ease, and latch not reachable to exit gate; back patio observed covered with dried bird droppings, tile flooring throughout living area, kitchen, and dining area observed unswept; and numerous empty and full boxes observed stored in open front office area and in garage.
3. Box of knives observed stored in closet where cleaners/chemicals are kept.
4. Nonperishable food was not of minimum of one week supply.

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

The following updated forms to be sent to CCL within 2 weeks:


-LIC500, LIC400, LIC402, LIC610D (new revision)

Exit interview conducted and a Plan of Correction was reviewed and developed with Licensee. A copy of this report and appeal rights was given to Licensee Eesaeng Martinez, whose signature confirms receipt of this report.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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 9
Document Has Been Signed on 11/22/2022 01:14 PM - It Cannot Be Edited


Created By: Malia Thao On 11/22/2022 at 11:51 AM
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: MARTINEZ RESIDENCE
FACILITY NUMBER: 547209005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility 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 observations and interview, the licensee did not comply with the section cited above. Exterior fire exit gate observed sticking and not opening/closing with ease, and latch not reachable to exit gate; back patio observed covered with dried bird droppings, tile flooring throughout living area, kitchen, and dining area observed unswept; and numerous empty and full boxes observed stored in open front office area and in garage, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will submit proof of exterior fire exit gate opening/closing with ease and with operating latch so that it will be accessible from the inside of the backyard, back patio cleaned of bird droppings, tile flooring in living area, kitchen, and dining room swept, and empty/full boxes to be removed or organized so as not to create a fire hazard in front office and garage, to CCL by POC due date.
Type B
Section Cited
CCR
80076(a)(15)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. Box of knives observed stored in closet where cleaners/chemicals are kept, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2022
Plan of Correction
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Licensee immediately removed box of knives and stored it in the inaccessible medication cabinet in the kitchen. POC cleared during the inspection.
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: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 11/22/2022 01:14 PM - It Cannot Be Edited


Created By: Malia Thao On 11/22/2022 at 11:51 AM
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: MARTINEZ RESIDENCE
FACILITY NUMBER: 547209005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in. Nonperishable food was not of minimum of one week supply, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will submit proof of purchase of additional nonperishable food to meet the minimum requirement of one week supply to CCL by POC due 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2022 01:14 PM - It Cannot Be Edited


Created By: Malia Thao On 11/22/2022 at 12:17 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: MARTINEZ RESIDENCE
FACILITY NUMBER: 547209005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020 Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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. LPA observed fire extinguisher in kitchen area was last serviced 9/16/21, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2022
Plan of Correction
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Licensee will submit proof of newly serviced fire extinguisher to CCL by POC due date. POC cleared during 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: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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