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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201663
Report Date: 11/30/2023
Date Signed: 12/05/2023 04:18:17 PM

Document Has Been Signed on 12/05/2023 04:18 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:SERENITY LIVINGFACILITY NUMBER:
107201663
ADMINISTRATOR:JONES, JOSIANEFACILITY TYPE:
740
ADDRESS:2605 W. BARSTOW AVENUETELEPHONE:
(559) 449-0504
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 3DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Josiane JonesTIME COMPLETED:
04:37 PM
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On 11/30/23 Licensing Program Analysts (LPA's) M. Garza and L. Salazar arrived at facility for an unannounced annual inspection visit. LPA's was met with Care Staff, Elaine Sauceda. LPA's introduced selves, explained reason for visit and were permitted entry into the facility. Licensee, Josiane Jones was contacted and arrived some time later.

LPA's completed a health and safety check on residents in care. 3 of 3 residents observed having breakfast in the living room area. LPA's toured the facility inside and out. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 8/22/23. Last fire drill on 9/16/23. 3 of 4 resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets and in good repair. Sharps located in a locked laundry room closet. LPA's observed sufficient seating under covered patio areas. LPA L. Salazar completed records review.

The following issues were observed at time of visit: Water temperature in bathroom #1 measured at 127.8 degrees F. Water temperature in kitchen measured at 138.7 degrees F. Food was stored in closet off the kitchen and observed to be locked. Medications were located off the kitchen in a closet and observed to be unlocked. Sign on kitchen cabinet towards living room stating "effective immediately, staff only beyond this point (no exceptions)", R1 has full bed rails, chemicals observed in hallway closet unlocked, freezer in garage needs to be defrosted, side gate #1 observed to be without latch, side gate #2 observed to be without latch and locked, right side back yard fence leaning and in need of repair.

CONT...

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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 2
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: SERENITY LIVING
FACILITY NUMBER: 107201663
VISIT DATE: 11/30/2023
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CONT...

LPA's requested the following documents to be submitted to CCL by 12/7/23: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

The following resources were provided to Licensee: Entrance Checklist (LIC 9242), Resources for Dementia training, Training Regulation (87707), Function Capabilities Form (LIC 9172), Reappraisal regulation (87463), Medication Training Regulation (H&S 1569.9), and TSP for Hospice Care and Medication Guide,

Due to time constraints LPA's will return to complete an annual continuation visit. Deficiencies (if any) will be cited at that time. Exit interview completed with Licensee and a copy of this report was provided.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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