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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206861
Report Date: 11/21/2022
Date Signed: 11/21/2022 10:42:38 PM

Document Has Been Signed on 11/21/2022 10:42 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:BELMAR VILLAFACILITY NUMBER:
107206861
ADMINISTRATOR:HRIPSIME MAKARYANFACILITY TYPE:
740
ADDRESS:2020 NORTH WEBER AVENUETELEPHONE:
(559) 486-5977
CITY:FRESNOSTATE: CAZIP CODE:
93705
CAPACITY: 100CENSUS: 66DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Makaryan "Christina" Hripsime, AdministratorTIME COMPLETED:
01:35 PM
NARRATIVE
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On 11/21/22 at 8:30 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and Administrator (ADM) Hripsime "Kristina" Makaryan was notified via telephone. ADM arrived approximately 45 minutes later.

Facility was toured with ADM. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bedrooms were checked. LPA checked residents' medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is valid.
The following deficiencies were observed:
1. S1 was working at the reception desk which is part of the facility and is accessible to residents in care. S1 does not have criminal record clearance. ADM advises S1 has been periodically asked to work the reception desk for a duration of 2-3 months now.
2. In room 309, the right side of window sill was observed lifted from the base with nails exposed.
3. All bedroom and bathroom waste baskets, and trash cans in hallways do not have tight-fitting lids.

Deficiencies are being cited based on LPA observation and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days, for a total of $500. See LIC421BG for more details.



Continue on LIC809-C.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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 11/21/2022 10:42 PM - It Cannot Be Edited


Created By: Malia Thao On 11/21/2022 at 11:48 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: BELMAR VILLA
FACILITY NUMBER: 107206861

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. In room 309, the right side of window sill was observed lifted from the base with nails exposed, which poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 12/05/2022
Plan of Correction
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Administrator will submit proof of right side of window sill in room 309 as repaired so that the window sill is nailed down to base with no exposed nails to CCL by POC due date.
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. All bedroom and bathroom waste baskets, and trash cans in hallways do not have tight-fitting lids, which poses a potential health or personal rights risk to residents in care.
POC Due Date: 12/05/2022
Plan of Correction
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Administrator will submit proof of purchase of waste baskets with lid for all bedrooms, bathrooms, and hallways 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: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2022 10:42 PM - It Cannot Be Edited


Created By: Malia Thao On 11/21/2022 at 12:18 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: BELMAR VILLA
FACILITY NUMBER: 107206861

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above. S1 was working at the reception desk which is part of the facility and is accessible to residents in care. S1 does not have criminal record clearance. ADM advises S1 has been periodically asked to work the reception desk for a duration of 2-3 months now, which poses an immediate health, safety, or personal rights risk to residents in care.
POC Due Date: 11/22/2022
Plan of Correction
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Administrator will submit a written statement stating S1 will discontinue working in the facility until ADM has confirmed criminal record clearance has been obtained, to CCL by POC due date.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022


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: BELMAR VILLA
FACILITY NUMBER: 107206861
VISIT DATE: 11/21/2022
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Continued from LIC809.

The following updated forms are to be submitted to CCL within 2 weeks:

LIC610E

- Due to time constraints, LPA will return for an annual continuation inspection on a later date to address additional concerns. Deficiencies may be cited during next inspection.

- ADM is to submit a food service plan to update the facility's plan of operation to CCL by 12/5/22.

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

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC809 (FAS) - (06/04)
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