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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208977
Report Date: 07/25/2024
Date Signed: 07/25/2024 06:45:27 PM

Document Has Been Signed on 07/25/2024 06:45 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:JAN-ROY PLACE OF FRESNOFACILITY NUMBER:
107208977
ADMINISTRATOR/
DIRECTOR:		HOPPER, JOYCELYNFACILITY TYPE:
740
ADDRESS:4766 EAST ILLINOIS AVETELEPHONE:
(559) 940-9708
CITY:FRESNOSTATE: CAZIP CODE:
93702
CAPACITY: 6CENSUS: 5DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator, Joycelyn HopperTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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On 07/25/2024, Licensing Program Analysts (LPAs) K.Kaur and M. Vega arrived at the facility unannounced to conduct an Annual Required Inspection. LPAs introduced selves, stated the purpose of the visit and was allowed entry into the facility by staff Lilia Yumol. Facility Staff contacted Administrator, Joycelyn Hopper via telephone. Administrator arrived a short time later.

LPAs toured the facility inside and out. Facility observed to be clean, odor free and at a comfortable temperature. Pathways and doors were clear and free from obstruction. 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 1/14/2024. Resident rooms observed to have the required furnishings. LPA observed sufficient seating in living room. At 12:43 PM LPAs observed the centrally stored medication cabinet was unlocked. Tour continued to Kitchen and dining area which were clean and had sufficient seating. At 12:48 PM LPAs did not observe a 7-day supply of non-perishable foods. At 12:50 PM LPAs observed cleaning supplies and chemicals unlocked in a cabinet under the kitchen sink. Laundry area and office toured. Office has locked chemicals and sharps. LPA observed freezer in the garage. The exterior tour was conducted. The backyard was observed to have sufficient seating. At 12:53 PM LPAs observed a patio that was under construction. LPAs interviewed Licensee and were informed CCLD was not informed, and a permit has not been obtained. At 12:56 PM LPAs observed paint cans in the open garage. Backyard gate is self-closing and self-latching.

Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report


and ID Documentation. Staff files were reviewed for good health. At 3:38 PM LPAs observed PRN medication was not logged with the required information. At 3:42 PM LPAs observed live in staff had an expired CPR certificate. At 4:14 PM LPAs reviewed residents P & I records and observed resident’s monies were deposited into a bank account that also holds facility funds.

Continued to Next Page
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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 9
Document Has Been Signed on 07/25/2024 06:45 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/25/2024 at 04:30 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: JAN-ROY PLACE OF FRESNO
FACILITY NUMBER: 107208977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1; Licensee is having a patio add-on built and has not obtained a permit; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Licensee to submit statement of intent to obtain a permit for patio cover by due date. Submit documentation of permit once obtained.
Type A
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 observation, the licensee did not comply with the section cited above in 2 out of 2; LPAs observed unlocked chemicals and cleaning supplies under the kitchen sink and paint cans in the garage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee locked kitchen cabinet and closed garage during inspection. Licensee to provide in service training for chemical storage and submit when completed.
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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 07/25/2024 06:45 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/25/2024 at 04:30 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: JAN-ROY PLACE OF FRESNO
FACILITY NUMBER: 107208977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 1 out of 1, record review revealed live in staff CPR/first aid certification was expired, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee to have staff complete CPR/first aid certification.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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, LPAs observed medication cabinet was unlocked during facility tour, and LPAs observed Medication for 7/26/2024 was removed from its bubble pack and placed in plastic tubber ware containers which were left unlocked in the kitchen cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee immediately secured medication, Licensee to submit statement of intent to provide in service training.
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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/25/2024 06:45 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/25/2024 at 04:30 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: JAN-ROY PLACE OF FRESNO
FACILITY NUMBER: 107208977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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, LPAs did not observe 7 day supply of nonperishable food, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee to restock nonperishable food supply and provide pictures with receipts as verification.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

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 5 residents, medication was not logged in LIC 622 Centrally Stored Medication and Destruction Record (CSMDR), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Licensee to log all medication into CSMDR and provide copies of records.
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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/25/2024 06:45 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/25/2024 at 04:30 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: JAN-ROY PLACE OF FRESNO
FACILITY NUMBER: 107208977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

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 5 residents PRN medication was not logged with the required information, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee to provide in service training to staff and submit documents by due date.
Type B
Section Cited
CCR
87217(e)
87217 Safeguards for Resident Cash, Personal Property, and Valuables (e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the use of his own or the facility's funds and valuables. This does not prohibit the licensee from providing advances or loans to residents from facility money.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 5 out of 5 residents P & I was commingled with facility funds which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee to ensure residents funds are deposited into a separate bank account that does not have facility funds. Licensee plans to open another bank account with resident’s funds only.
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: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


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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: JAN-ROY PLACE OF FRESNO
FACILITY NUMBER: 107208977
VISIT DATE: 07/25/2024
NARRATIVE
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Deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D.

LPA requested the following documents to be submitted to CCL by 8/1/2024: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.



Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights was discussed and provided to Administrator, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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