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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202520
Report Date: 01/22/2024
Date Signed: 01/22/2024 03:46:56 PM

Document Has Been Signed on 01/22/2024 03:46 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:ROYAL GARDENS IVFACILITY NUMBER:
107202520
ADMINISTRATOR:GURMIT K AULAKHFACILITY TYPE:
740
ADDRESS:1125 SUNNYSIDE AVE.TELEPHONE:
(559) 765-4905
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Administrator Gurmit AulakhTIME COMPLETED:
04:00 PM
NARRATIVE
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On 01/22/24, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry by Jamaila Keith Andrada. Gurmit Aulakh, Administrator was called and arrived shortly after. Six residents were present during the inspection.

LPA toured facility with caregiver. 7-day supply of non-perishable foods and a 2-day supply of perishable foods observed. Knives and cleaning supplies are locked in the kitchen cabinet under the sink. Additional Cleaning and Chemical supplies are kept in locked cabinet in the garage. At 9:36 AM LPA observed Insect Killer spray container unlocked and accessible to residents. Fire extinguisher serviced on 2/13/2023. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available. Carbon monoxide and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid mats in place.

All pathways, entrances and exits were clear from obstruction. The facility was observed to be at a comfortable temperature, in good repair. Common areas were properly furnished and well-lit throughout. There is one resident on hospice at this time. The dining room is equipped with a table and chairs, living room is equipped with adequate sofas and recliners for six residents, adequate outside space for rest and recreational. LPA toured outside and observed sufficient seating under patio area. Backyard gate is self-closing and self-latching. At 10:06 AM LPA observed a BBQ grill hooked up to gas tank accessible to resident with dementia.

Last fire drill conducted on 1/14/2024. At 11:23 PM LPA reviewed resident's medication, MARS, and Centrally Stored Medication and Destruction Record (CSMDR) and observed medication was not logged in the log. LPA reviewed resident records and observed 3 resident’s missing property inventory list.

Continued to LIC809C…
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
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 01/22/2024 03:46 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 01/22/2024 at 02:41 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: ROYAL GARDENS IV
FACILITY NUMBER: 107202520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 Insect Killer spray container unlocked in the garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Staff removed container and placed in locked area. Citation corrected during inspection.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents medication were not logged in the centrally stored log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Licensee to log all medication into centrally stored log and ensure all information is accurate and documented. Licnesee to submit completed logs to CCLD by 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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/22/2024 03:46 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 01/22/2024 at 02:41 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: ROYAL GARDENS IV
FACILITY NUMBER: 107202520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

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 1 out of 1 residents physicans report was not current which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Licensee to schedule an appointment for medical re-assessment and inform CCLD by due and submit a copy of the completed form after appointment.
Type A
Section Cited
CCR
87705(d)
Care of Persons with Dementia
(d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 BBQ grill accessible to resident with dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Administrator removed the Gas tank connection from the BBQ grill.
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: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/22/2024 03:46 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 01/22/2024 at 02:41 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: ROYAL GARDENS IV
FACILITY NUMBER: 107202520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.153(d)
Licensing
(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 6 resident’s missing property inventory list which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2024
Plan of Correction
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Licnesee to complete a Inventory list for residents and submit to CCLD by due date and ensure residents inventory list are updated as needed in the future.

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: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


LIC809 (FAS) - (06/04)
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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: ROYAL GARDENS IV
FACILITY NUMBER: 107202520
VISIT DATE: 01/22/2024
NARRATIVE
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Resident Admission agreement needs/services plan, and emergency identification complete. Based on observation and interview LPA observed one resident did not have updated physician report based on current physical abilities. Staff files reviewed and complete. Staff verified to have CPR/First aid training.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/29/2024: 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, 809D with
appeal rights were provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
LIC809 (FAS) - (06/04)
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