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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209219
Report Date: 07/10/2024
Date Signed: 07/10/2024 03:14:37 PM


Document Has Been Signed on 07/10/2024 03:14 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:KAWEAH HEALTH RUTH WOOD OPEN ARMS HOUSEFACILITY NUMBER:
547209219
ADMINISTRATOR:SALAZAR, DEBORAHFACILITY TYPE:
740
ADDRESS:3234 W. IRIS AVE.TELEPHONE:
(559) 625-0139
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:6CENSUS: 3DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Deborah Salazar and Jacklyn Becerra TIME COMPLETED:
03:30 PM
NARRATIVE
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On 7/10/2024, 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 Administrator Jacklyn Becerra. Administrator Deborah Salazar arrived shortly after.

LPA conducted facility tour with Administrator Jacklyn Becerr. All pathways, entrances and exits were clear from obstructions. The tour started in kitchen, continued to dining room, living room and resident rooms. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Sharps are locked in kitchen cabinet. Facility Laundry room is connected to Kitchen. Laundry room observed locked with cleaning supplies and chemicals. Office area observed with back up supplies and cleaning supplies; Office is kept locked when no one present. Dining room and Living room observed with sufficient seating and activities for residents. Facility has three resident at this time. LPA toured several bedrooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. Fire extinguisher in hallway was last serviced on 7/2/2024 and was fully charged. Carbon monoxide and smoke alarm detectors installed and operational. Linen supply is kept in the hallway closet. Medications are kept in locked cabinets in the hallway. Last fire drill conducted on 5/17/2024. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Medication Audit conducted. Staff files were reviewed for good health. 2 out of 3 staff were not associated with the facility. It was verified that current staff on duty is CPR certified. LPA observed sufficient seating under covered patio area in the back of the facility. Side gate was self-closing and self-latching.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Immediate Civil Penalty assessed for caregiver background check.

Continued to LIC809C
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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 5


Document Has Been Signed on 07/10/2024 03:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: KAWEAH HEALTH RUTH WOOD OPEN ARMS HOUSE
FACILITY NUMBER: 547209219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

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 staff are fingerprint cleared but not associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Facility faxed in the LIC 9182 Fingerprint transfer request for S1 and S2 to Fresno CCLD.
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 MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: KAWEAH HEALTH RUTH WOOD OPEN ARMS HOUSE
FACILITY NUMBER: 547209219
VISIT DATE: 07/10/2024
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LPA is requesting the following documents be submitted to the Fresno CCL office by 7/17/2024: Current copy. of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a copy of this report was provided with appeal rights.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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