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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107207121
Report Date: 12/19/2024
Date Signed: 12/19/2024 06:49:42 PM

Document Has Been Signed on 12/19/2024 06:49 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:NINA'S HOMEFACILITY NUMBER:
107207121
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, LETICIAFACILITY TYPE:
740
ADDRESS:6540 N. BRIARWOODTELEPHONE:
(559) 253-3024
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 5DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:12 AM
MET WITH:Administator, Phoung MarezTIME VISIT/
INSPECTION COMPLETED:
06:59 PM
NARRATIVE
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On 12/19/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Direct Care Staff, Elizabeth, explained reason for visit and was permitted entry into the facility. Staff, Mark Fuentes was contacted and arrived a short time later. Administrator, Phoeun Marez was contacted and arrived some time later.

LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There was 2 residents on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was 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 . Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Chemicals and medications were located in locked closets/rooms. LPA observed sufficient seating under covered patio areas.

The following issues were observed during todays visit: Scissors were observed in nook area unlocked and accessible to residents in care. Staff at facility upon arrival did not have CPR/1st Aid. Water temperature measured at 129.7 degrees F. Living room carpet has hole near transition from living room to kitchen. Dog urine in master bathroom. Master bedroom has dirty brief. Carpet in master bedroom doorway was lifted and in need of repair. Flooring in hallway bathroom observed lifting and in need of repair. Bedroom #3 observed with paint in need of touch up near night stand. Inside refrigerator observed with liquid at the bottom in need of cleaning. Inside refrigerator missing racks in freezer. Hole in garage behind door in need of repair. Debris observed behind washer and dryer in need of cleaning. Left side gate is not self-latching. Concrete on patio observed with moss in need of cleaning.
CONT...
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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 12/19/2024 06:49 PM - It Cannot Be Edited


Created By: Mary Garza On 12/19/2024 at 05:40 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: NINA'S HOME
FACILITY NUMBER: 107207121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that the facilities disaster prepardness plan was present but not updated with accurate information. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Administrator stated that disaster plan will be updated and completed and submitted to CCL by POC date.
Type A
Section Cited
CCR
87555(a)
87555 General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation facility did not have the required 7-day non-perishable food supply, the licensee did not comply with the section cited above. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Groceries will be purchased and a copy of the reciept will be provided to CCL by POC 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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/19/2024 06:49 PM - It Cannot Be Edited


Created By: Mary Garza On 12/19/2024 at 05:40 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: NINA'S HOME
FACILITY NUMBER: 107207121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 LPA observation, the licensee did not comply with the section cited above in scissors being observed in the nook area drawer unlocked and accessible to residents in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Administrator to collect items posing a danger to residents in care and lock/make inaccessible to residents in care. Administrator stated training will be completed with staff. In-service sign in sheet and training material will be submitted to CCL as proof of correction.
Type B
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of the following: Living room carpet has hole near transition from living room to kitchen. Dog urine in master bathroom. Master bedroom has dirty brief. Carpet in master bedroom doorway was lifted and in need of repair. Flooring in hallway bathroom observed lifting and in need of repair. Bedroom #3 observed with paint in need of touch up near nightstand. Inside refrigerator observed with liquid at the bottom in need of cleaning. Inside refridgerator missing racks in freezer. Hole in garage behind door in need of repair. Debris observed behind washer and dryer in need of cleaning. Left side gate is not self-latching. Concrete on patio observed with moss in need of cleaning. Refridgerator in garage leaking liquid. Freezer observed with severe frost bite and refrigerator missing shelves in need of replacement/repair. Garage door observed dirty and in need of cleaning. Garage observed with clutter in need of removal. The licensee did not comply with the section cited above. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Administrator stated corrections will be made to the issues listed above. Once correction has been made a picture will be sent to CCL as proof of correction.
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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


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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: NINA'S HOME
FACILITY NUMBER: 107207121
VISIT DATE: 12/19/2024
NARRATIVE
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CONT...

Refrigerator in garage leaking liquid. Freezer observed with severe frost bite and refrigerator missing shelves in need of replacement/repair. Garage door observed dirty and in need of cleaning. Food observed in pantry was not properly sealed. Expired food was observed in pantry. Food observed in outside refrigerator/freezer was severely frost bitten and in need of defrosting. Facility was not observed with the required 7-day non-perishable food source. Facility has Disaster Plan in place however, areas listed need to be update with accurate information.

LPA requested the following documents to be submitted to CCL by 12/27/24: 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.

Exit interview completed with Administrator, Phoeun. A copy of this report, deficiencies, TV's and appeal rights were provided.

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

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/19/2024 06:49 PM - It Cannot Be Edited


Created By: Mary Garza On 12/19/2024 at 06:31 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: NINA'S HOME
FACILITY NUMBER: 107207121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of water temperature measuring at 129.7 degrees F, the licensee did not comply with the section cited above. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Water heater immediately turned down. Administrator stated they will complete a water temperature log. Temperature will be tested 2xs daily in 2 separate locations. Water log will be submitted to CCL by POC date as proof of correction.
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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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