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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209134
Report Date: 05/06/2024
Date Signed: 05/06/2024 02:36:34 PM

Document Has Been Signed on 05/06/2024 02:36 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:DEENA'S CARE HOMEFACILITY NUMBER:
547209134
ADMINISTRATOR/
DIRECTOR:		PATCH, DEENAFACILITY TYPE:
735
ADDRESS:3537 W. CUTLER AVE.TELEPHONE:
(559) 679-4609
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 4DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:19 AM
MET WITH:Licensee Deena Patch TIME VISIT/
INSPECTION COMPLETED:
02:45 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 5/06/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA was allowed entry by care staff Febe Tinoco. Licensee Deena Patch was contacted and arrived a short while later.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed. Sharp items and medications are locked in the kitchen cabinet. Cleaning supplies were locked under the kitchen sink. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the kitchen was last serviced on 10/9/2023 and was fully charged. Common areas were properly furnished and well-lit throughout. LPA toured 3 private bedrooms with adequate furnishings and 2 restrooms observed to be clean, odor free and functioning at time of visit. Facility has in live in staff in one bedroom. Additional cleaning supplies and laundry detergent locked in garage. Hallway closet observed to have additional bedding, linens, and hygiene products. Backyard observed to have covered patio with sufficient seating. Backyard gate was self-latching and self-closing. A sample of medication was reviewed. Resident records were reviewed for updated emergency contact information and for all necessary documentation. LPA observed during medication review Centrally Stored medication and destruction record was missing information. Staff records were reviewed for health and first aid. Last Fire drill conducted on 2/21/2024.

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 5/13/2024: 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
(LIC610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with staff. Report signed on-site; and a printed copy was provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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 2
Document Has Been Signed on 05/06/2024 02:36 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 05/06/2024 at 02:26 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: DEENA'S CARE HOME
FACILITY NUMBER: 547209134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

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 4 out of 4 centrally stored medication list observed incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
1
2
3
4
Licensee to fill out missing information on Centrally Stored Medication and Destruction log and submit to CCLD by due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
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: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


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