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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209374
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:48:47 PM

Document Has Been Signed on 10/29/2024 02:48 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:GRAND OAKS ASSISTED LIVINGFACILITY NUMBER:
547209374
ADMINISTRATOR/
DIRECTOR:		SHELLHAMER, DAVIDFACILITY TYPE:
740
ADDRESS:999 NORTH M STREETTELEPHONE:
(559) 684-1001
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 85CENSUS: 48DATE:
10/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:36 AM
MET WITH:Wendi Valdez - Resident Care Coordinator TIME VISIT/
INSPECTION COMPLETED:
03:00 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 10/29/2024, Licensing Program Analysts (LPAs) K.Kaur and L. Salazar arrived unannounced to deliver findings on subsequent complaint visit.

A resident (R1) approached LPAs and informed LPAs of a roommate that went to a hospital and disclosed details of the resident’s condition. LPAs reviewed (R2’s) file and interviewed staff. Based on interview R2 is on home health. LPA reviewed resident home health visit history. Further review of files revealed Facility did not have a Home Health Care Plan on file. Resident Care Coordinator requested and received Home Health Care plan. LPAs reviewed Care plan and observed a prohibited health condition was diagnosed from September 9, 2024.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with staff. Administrator was contacted via phone to review the findings. Report signed on-site by . Resident Care Coordinator and printed copy provided with appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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 3
Document Has Been Signed on 10/29/2024 02:48 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 10/29/2024 at 11:54 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: GRAND OAKS ASSISTED LIVING
FACILITY NUMBER: 547209374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited
CCR
87615(a)(4)

1
2
3
4
5
6
7
87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (4)…infection or other serious infection.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to schedule an in-service training on restricted and prohibited health conditions and provide documentation of training when completed. Administrator agrees to submit a statement of understanding of steps required for prohibited health conditions by POC date.
8
9
10
11
12
13
14
Based on LPA's observation of records review and interview with Staff R2 was sent to hospital on10/29/2024 due to a serious infection diagnosed on 9/9/2024.
8
9
10
11
12
13
14
Type A
10/30/2024
Section Cited
CCR87609(4)(C)

1
2
3
4
5
6
7
87609 Allowable Health Conditions and the Use of Home Health Agencies (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). (C)The written agreement shall be signed by the licensee or licensee representative, and representative of the home health agency, and placed in the resident’s file.
1
2
3
4
5
6
7
Residential Care Coordinator contacted the Home Health agency during the time of visit and was able to obtain the Plan of Care for R2. Plan of Correction completed during visit. Administrator will provide a list of residents who are receivng Home health care services to LPA. Administrator will verify all residents have a care plan in file.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
LPAs request for R2's Home Health care plan. During File review, LPAs did not observe a Plan of Care between Therapeutic Home Healthcare and Facility regarding a serious infection and how to care for it.
8
9
10
11
12
13
14
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: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/29/2024 02:48 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 10/29/2024 at 01:23 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: GRAND OAKS ASSISTED LIVING
FACILITY NUMBER: 547209374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2024
Section Cited
CCR
87211(a)

1
2
3
4
5
6
7
87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to conduct in-service training on reporting requirements provide documentation of training when completed.
8
9
10
11
12
13
14
Facility did not submit an incident report for (R2) who was referred to their PCP for a change of health condition/ injury on 8/28/2024.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3