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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209037
Report Date: 08/01/2023
Date Signed: 08/01/2023 01:09:09 PM

Document Has Been Signed on 08/01/2023 01:09 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:J&M HOMEFACILITY NUMBER:
547209037
ADMINISTRATOR:SANDOVAL, JAREDFACILITY TYPE:
735
ADDRESS:616 W LOYOLA AVETELEPHONE:
(559) 409-2803
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 4CENSUS: 4DATE:
08/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Jared SandovalTIME COMPLETED:
01:15 PM
NARRATIVE
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On 8/01/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Licensee Jared Sandoval. Residents were attending day program.

All pathways, entrances and exits were clear from obstructions. LPA and Licensee began tour at the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in kitchen was last serviced on 5/10/2023 and was fully charged. Tour continued to the living room which has sufficient seating. LPA toured three resident rooms upstairs which were observed to be furnished with required furniture and adequate lighting. At 10:33 AM LPA observed the resident bedroom carpet to have stains. Master bedroom and bathroom were observed with debris on the floor; bathrooms and showers observed with stains. Linen supply is kept in the Hallway closet upstairs. Cleaning supplies and chemicals are kept locked in the laundry room and garage. Medications are kept locked in the cabinets in the laundry room. LPA observed sufficient seating under covered patio area. Backyard gate was self-latching and self-closing. Carbon monoxide and smoke alarm detectors installed and operational. LPA reviewed resident’s medication and Centrally Stored List for any residents. Resident's records contained signed Admission Agreement, and current Physician's Report. Frill Drill records were reviewed. At 11:46 LPA observed Staff files were missing Health screening and TB results. Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 8/15/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization
(LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan
(LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Staff. Report signed on-site by staff and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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 08/01/2023 01:09 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 08/01/2023 at 12:21 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: J&M HOME
FACILITY NUMBER: 547209037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 2 persons employees files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Licensee to schedule Health screening for TB test and submit copies of report to CCLD by 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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/01/2023 01:09 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 08/01/2023 at 12:21 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: J&M HOME
FACILITY NUMBER: 547209037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023

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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4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2023
Plan of Correction
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Licensee to clean residents rooms and bathroom and submit pictures to CCLD by due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
4
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:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
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