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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208807
Report Date: 09/28/2023
Date Signed: 09/28/2023 04:19:42 PM

Document Has Been Signed on 09/28/2023 04:19 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:MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCOFACILITY NUMBER:
107208807
ADMINISTRATOR:BRICE, NASTASSHAFACILITY TYPE:
740
ADDRESS:149 OAK AVENUETELEPHONE:
(559) 765-4287
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 5DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Administrator Ma Divinagr (Grace) PetilTIME COMPLETED:
04:45 PM
NARRATIVE
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On 9/28/2023, Licensing Program Analysts (LPAs) K. Kaur and L.Padgett arrived unannounced at the above facility to conduct an Annual Inspection. LPAs introduced themselves, stated the purpose of the visit and met with Administrator MaDavina (Grace) Petil (AD). LPAs conducted facility tour with AD and Staff Tirso Petil (S1).

LPAs toured kitchen and dining areas. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed non-perishable and perishable foods. Carbon monoxide detector in the kitchen was tested operational. Smoke detectors were observed in all bedrooms and the hallways, tested, observed operational.

Office is in converted garage space. In the laundry room, detergent and cleaning supplies are kept in locked cabinets. LPAs observed facility common areas which were furnished with sufficient seating.

LPAs toured five resident rooms which were observed to be furnished with required furniture and adequate lighting. At 9:05am LPAs observed some dust debris in resident bedrooms. LPAs observed one cracked tile and slight lift on the transition floorboard at the entrance of bedroom 5. Bathrooms were properly equipped with non-slip mats and grab bars. At 9:43 AM Padgett tested water temperature in the hallway bathroom sink at 92.8°F and the bathroom in bedroom 5 91.4°F. At 9:41am LPA Kaur observed 5 out of 5 stove knobs accessible to residents while no staff were present in the kitchen and or cooking.

Bedroom 5 has door that leads to the backyard. LPA Kaur attempted to open this door, but it was stuck and difficult to open. S1 was able to open the door. Once this door was open, LPA’s observed what appears to be water damage and rot at the inner right corner of the door at the base. This exit opens to covered patio area with sufficient seating and shade for recreational purposes. There was visible rot and damage to the fascia and roof of the patio. On the patio roof area just above the Bedroom 5 exterior door is a gap between the home fascia and the patio fascia.

Continued to next Page

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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 6
Document Has Been Signed on 09/28/2023 04:19 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 09/28/2023 at 02:16 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: MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO
FACILITY NUMBER: 107208807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
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 degrees C) and not more than 120 degree F (49 degrees C).

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 water temperature check readings 91.4 master, and 92.8 Hallway which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licnesee to adjust water heater and test the water temperature to ensure reading is between 105 to 120
Type A
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by 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 2 out of 2 resident files Resident (R2) had no TB clearance. (R3) TB test was completed but the results were not read/ documented which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee to schedule doctor’s appointment to complete TB testing for residents and submit the scheduled time of appointment to CCLD by due date and follow up with the results once the reading is complete.
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: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/28/2023 04:19 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 09/28/2023 at 02:16 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: MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO
FACILITY NUMBER: 107208807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 and record review, the licensee did not comply with the section cited above in 2 out of 4 residents medication audit Residents (R1) and (R4) did not have a Centrally Stored Medication and Destruction Record which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator to complete a Centrally Stored Medication and Destruction Record for all residents and submit copies to CCLD by due date.
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 and interview, the licensee did not comply with the section cited above in 5 out of 5 Stove knobs observed while no staff was present in kitchen/and or cooking which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator to ensure knobs are removed if not cooking or place locks on the knobs. Administrator removed during inspection. **POC completed during inspection.**
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: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/28/2023 04:19 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 09/28/2023 at 02:16 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: MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO
FACILITY NUMBER: 107208807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

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 observation, the licensee did not comply with the section cited above in 3 out of 5 resident rooms observed with debris on floor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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Administrator to complete deep cleaning of all resident bedrooms and submit pictures by the due date and develop a cleaning schedule to ensure clean and sanitary environment.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 4 out of 4 Building and structural damage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licnesee to repair hallway drywall damage, cracked Tile and transition into bedroom 5, Bedroom 5’s exit door that and patio and submit to CCLD pictures of corrections 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: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/28/2023 04:19 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 09/28/2023 at 03:16 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: MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO
FACILITY NUMBER: 107208807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203


87203 FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the
protection of life and property against fire and panic.

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. Fire extinguisher was expired
with a service date of 7/20/2022, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee to have either fire extinguisher serviced or buy new extinguisher and submit pictures as proof of POC.
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:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCO
FACILITY NUMBER: 107208807
VISIT DATE: 09/28/2023
NARRATIVE
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There, the roof area appears to be rotting. R2 stated that when it rains the covered patio area floods. Backyard gate was self-closing and self-latching. At 2:35pm LPA Kaur observed Fire extinguisher in kitchen was expired with a service date of July 20, 2022.

Medications are kept in locked pantry in the kitchen. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. AD stated that she and S1 are the only employees. Staff files were reviewed for health screening and first aid/CPR certified. Last fire drill conducted on 8/7/2023.

At 1:20 PM LPA’s reviewed resident's medication, MARS, and Centrally Stored Medication and Destruction Record (CSMDR) and observed (R1) and (R4) did not have a Centrally Stored Medication and Destruction Record. During Resident records review 2 of the 5 residents were observed to be without TB clearance.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/5/2023: 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: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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