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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400448
Report Date: 08/01/2023
Date Signed: 08/01/2023 05:20:15 PM

Document Has Been Signed on 08/01/2023 05:20 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:NAZARETH HOUSEFACILITY NUMBER:
100400448
ADMINISTRATOR:O'NEILL, ROSEMARY, R.N.FACILITY TYPE:
740
ADDRESS:2121 NORTH FIRST STREETTELEPHONE:
(559) 237-2257
CITY:FRESNOSTATE: CAZIP CODE:
93703
CAPACITY: 110CENSUS: 69DATE:
08/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Sara Guidry, Assistant Administrator TIME COMPLETED:
05:00 PM
NARRATIVE
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On 8/1/23 at 1:07 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual Continuation inspection. LPA explained reason for inspection and met with Assistant Administrator Sara Guidry.

LPA completed the Inspection Tool and reviewed records.

The following deficiencies were observed:

1. S3 and S4 did not have TB results.
2. R5 did not have TB results and was admitted to the facility on 3/9/23.

Deficiency is being cited based on LPA's observation conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Assistant Administrator Sara Guidry. A copy of this report and appeal rights were given to Assistant Administrator, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
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 05:20 PM - It Cannot Be Edited


Created By: Malia Thao On 08/01/2023 at 04:28 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: NAZARETH HOUSE
FACILITY NUMBER: 100400448

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA found that S3 and S4 did not have TB results, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 08/15/2023
Plan of Correction
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Licensee will submit proof of TB results for S3 and S4, to CCL by POC 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
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 05:20 PM - It Cannot Be Edited


Created By: Malia Thao On 08/01/2023 at 04:28 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: NAZARETH HOUSE
FACILITY NUMBER: 100400448

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA found that R5 did not have TB results and was admitted to the facility on 3/9/23, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 08/15/2023
Plan of Correction
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2
3
4
Licensee will submit proof of TB results for R5 to CCL by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
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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