<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209037
Report Date: 06/27/2024
Date Signed: 06/27/2024 04:56:13 PM

Document Has Been Signed on 06/27/2024 04:56 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/
DIRECTOR:		SANDOVAL, JAREDFACILITY TYPE:
735
ADDRESS:616 W LOYOLA AVETELEPHONE:
(559) 409-2803
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 4CENSUS: 4DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Licensee Jared SandovalTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/27/2024, 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. Three residents were present during inspection.

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. Dinning area observed with table and chairs. Staff room next to the dining area toured. At 2:06 PM Laundry area toured and observed to have unlocked chemicals, laundry soap and cleaning supplies. Fire extinguisher in kitchen was last serviced on 6/4/2024 and was fully charged. Tour continued to the living area which has sufficient seating. LPA toured three resident rooms upstairs which were observed to be furnished with required furniture and adequate lighting. At 2:12 PM LPA observed rug leading into bedroom was lifted and above the Transition strip. At 2:20 Master bedroom and bathroom were observed with debris on the floor; bathrooms and showers observed with stains. Master Shower observed to have black stain at the base of the wall tile. Bedrooms observed to have debris around corners and near furniture. Linen supply is kept in the Hallway closet upstairs. Hallway bathroom observed to have missing baseboard with nails sticking out. Medications are kept locked in the cabinets in the laundry room. LPA observed 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 all residents. Resident's records contained signed Admission Agreement, and current Physician's Report. Staff files were reviewed and had required documents. 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 7/5/2024: 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 Licensee. Appeal rights provided Report signed on-site by staff and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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 8
Document Has Been Signed on 06/27/2024 04:56 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 06/27/2024 at 04:11 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: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 3 bedrooms; Hallway bathroom has missing baseboard with nails sticking out, debris observed in Bedrooms and bathroom, Shower observed with black on grout, rug lifted from transition strip which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee to submit a statement of intent to clean repair/replace items listed above. Once issues have been addressed licensee to submit pictures to CCLD by due date.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 cabinet observed unlocked in laundry room that had cleaning supplies, chemicals, and laundry soap which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee to remove items to a locked area to repair lock and submit documention of replacment of parts by due date.
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: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8