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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206858
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:39:44 AM

Document Has Been Signed on 10/27/2023 11:39 AM - 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:A PLACE CALLED HOME RESIDENTIAL CARE 3FACILITY NUMBER:
107206858
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2822 CALIMYRNA AVETELEPHONE:
(559) 213-7251
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Licensee/Administrator David Murchison TIME COMPLETED:
11:45 AM
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On 10/27/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met caregiver Leizel “Liz” Jugal. LPA toured facility with caregiver. Licensee/Administrator David Murchison was called and arrived shortly during tour. All six residents were present during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway
obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. The temperature is maintained for refrigerator at 40 degrees F and freezer at -2 degrees F. Fire extinguisher was observed with a service date of: 02/09/23. Fire drill last completed:10/06/23.

LPA and Licensee observed medications that were ordered to be destroyed with former resident’s medication bottles were observed unlocked under kitchen counter. MARs were reviewed.

Cleaning supplies and chemicals stored and locked in garage and laundry room. Washer and dryer observed operational during inspection. All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured. Bathrooms were observed operational during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested at 115.5 degree F in the bathroom 1, 115 degree F in bathroom 2, and 114.3 degree F in bathroom 3.

Outside of facility toured and observed to be free of debris. Side gate observed self-closing and self-latching. Adequate outdoor seatings available for residents. Carbon monoxide and smoke detectors were tested and observed to be operational. All residents’ files were reviewed to have all the required documents. Staff are fingerprinted clear and associated to the facility.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2023 11:39 AM - It Cannot Be Edited


Created By: Mai Yang On 10/27/2023 at 11:12 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: A PLACE CALLED HOME RESIDENTIAL CARE 3
FACILITY NUMBER: 107206858

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA, Licensee, and caregiver observed a grocery bag full of medications that were supposed to be destroyed with 4 medication bottles for a former resident stored under kitchen counter unlock and accessible to residents in care, which poses an immediate health and safety risk to the residents.
POC Due Date: 10/28/2023
Plan of Correction
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Medications were immediately removed and locked in medication shelf. POC cleared during inspection.
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 Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023


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: A PLACE CALLED HOME RESIDENTIAL CARE 3
FACILITY NUMBER: 107206858
VISIT DATE: 10/27/2023
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A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 11/02/23. Forms requested: Lic 308, Lic 500, Lic 610E, and current liability insurance. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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