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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209013
Report Date: 12/13/2022
Date Signed: 12/13/2022 01:39:49 PM

Document Has Been Signed on 12/13/2022 01:39 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:ATTENTIVE SENIOR CARE II, LLCFACILITY NUMBER:
107209013
ADMINISTRATOR:HOLLAND, LAWRENCEFACILITY TYPE:
740
ADDRESS:6149 E LOWE AVETELEPHONE:
(916) 996-6215
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 6DATE:
12/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Paulette HollandTIME COMPLETED:
02:00 PM
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On 12/13/2022, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA was allowed entry by caregiver Crystal Brieske. Licensee Paulette Holland was contacted.

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Facility staff observed without facial coverings. Facility appeared clean and obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas. At 12:20 PM LPA observed the Fire extinguisher to be expired with a service date of 10/28/2021 in the Kitchen. All bathrooms observed with trash cans that have lids, and securely fastened grab bars. Bathrooms have non-skid mats. All resident’s rooms toured and observed to be adequately furnished and lit. LPA observed 3 shared resident’s bedrooms.


The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information. LPA checked residents’ locked medications. 30-day PPE supplies observed. Food supply was checked and appeared to be an adequate supply.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/23/2022: 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 for LIC9020.



An exit interview was conducted with Licensee. Report signed on-site by licensee; a copy of this report, appeal rights and printed provided
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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 12/13/2022 01:39 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 12/13/2022 at 12:58 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: ATTENTIVE SENIOR CARE II, LLC
FACILITY NUMBER: 107209013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022

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 extinguisher 10/28/2021, which poses an immediate health, safety or personal rights risk to persons in
care.
POC Due Date: 12/14/2022
Plan of Correction
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Licensee to either have fire extinguisher serviced or buy new extinguisher and submit pictures/Invoice 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: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022


LIC809 (FAS) - (06/04)
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