<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208813
Report Date: 11/03/2022
Date Signed: 11/07/2022 02:41:41 PM

Document Has Been Signed on 11/07/2022 02:41 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 HEART IS HOMES-CARMEL BY THE SEAFACILITY NUMBER:
107208813
ADMINISTRATOR:MAREZ, PHOEUNFACILITY TYPE:
740
ADDRESS:292 W TRENTON AVETELEPHONE:
(559) 298-7992
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 6DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Marez PhoeunTIME COMPLETED:
02:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/03/22, Licensing Program Analyst (LPA) V Gorban unannounced Annual Required Infection Control Inspection. LPA observed a central entry point with a supply of hand sanitizer located upon entry. A sign in policy that includes documented routine symptom screening for visitors is currently being implemented to follow current visitation guidelines. LPA introduced self and stated purpose of visit , LPA met with Marez Phoeun, Administrator Certificate #6031818740, expires 06/13/24.

Facility toured with Administrator. All six private bedrooms are single occupancy, fully furnished, some bedrooms share walk in showers and bathrooms. Residents present during today's inspection observed to be sitting in dining/activity areas after lunch watching a television and others resting in their bedroom. Kitchen toured, LPA observed facility to have a 2-day of perishable and a 7-day supply of non-perishable food available. Medications are locked and secured in medication room, residents observed to have a 30-day supply of medication available. PPE is locked and secured and available if necessary.

Carbon Monoxide detectors observed to be operational during today's inspection. Fire extinguishers present with a service date of 07/20/22.

Deficiencies observed, licensee did not pay annual fees, and documented on D form.

Exit interview conducted. Report signed on site and a copy provided to Administrator for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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 3
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 HEART IS HOMES-CARMEL BY THE SEA
FACILITY NUMBER: 107208813
VISIT DATE: 11/03/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 11/25/2022

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 11/07/2022 02:41 PM - It Cannot Be Edited


Created By: Vadim Gorban On 11/03/2022 at 01:15 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 HEART IS HOMES-CARMEL BY THE SEA
FACILITY NUMBER: 107208813

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87156(a)
An applicant or licensee shall be charged as specified in Health and Safety Code section1569.185.(a)....After initial licensure, a fee shall be charged by the department annualy on each anyversary of the effective date of the license.
This requirement is not met as evidenced by the facility licensing fees being past due in teh amount of $742.00. This is poses potential health and safety risc to residents in care.
Deficient Practice Statement
1
2
3
4
Annual Fees are not current.
POC Due Date: 11/24/2022
Plan of Correction
1
2
3
4
Licensee will pay the fees and provide receipt to the Department no later then due date stated earlier.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Brenda Chan
LICENSING EVALUATOR NAME:Vadim Gorban
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3