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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209086
Report Date: 12/26/2024
Date Signed: 12/26/2024 02:31:39 PM

Document Has Been Signed on 12/26/2024 02:31 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:BK HOUSE OF GRACE LLCFACILITY NUMBER:
107209086
ADMINISTRATOR/
DIRECTOR:		RIEMER, ROSEMARIE HFACILITY TYPE:
740
ADDRESS:1463 N ARCHIE AVENUETELEPHONE:
(559) 201-8329
CITY:FRESNOSTATE: CAZIP CODE:
93703
CAPACITY: 6CENSUS: 5DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH: Licensee Balwinder KaurTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 12/26/2024, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry by Licensee Balwinder Kaur.

Facility tour conducted. LPA toured the facility kitchen. LPA observed 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Medications checked. Medication observed to be locked and inaccessible to residents in care in the closet. Fire extinguisher observed in kitchen which was last serviced on 06/22/2024.

The dining area is equipped with a table and chairs, the living room is equipped with adequate sofas and recliners for seating. At 10:45 AM LPA observed the hallway closet to have an odor and observed water around the bathroom floor. At 11:14 AM LPA observed two window screen frames for bent. Medications, first aid kit observed locked in the hallway closet. Residents' bedrooms were observed to be adequately furnished with beds, dresser, and adequate lighting. Mattresses and linen were in good condition. LPA observed grab bars installed by toilet. At 11:48 AM LPA did not observe a non-skid mat or strips in the shower. Smoke alarm detectors installed and operational. At 12:29 PM LPA observed Carbon monoxide detector was not operational LPA toured outside and observed covered area for rest and recreational. Sufficient seating observed under a covered patio. LPA observed unlocked bleach and bug spray in the backyard that Licensee locked immediately.

LPA reviewed Resident and staff files and observed admission agreements, ID forms. 2 out of 5 residents did not have Appraisal and needs service plans. At 1:19 PM LPA observed 1 out of 5 residents did not have TB clearance documentation at the facility. LPA observed different administrator documentation than the one on file. LPA emailed Licensee the required documentation to make the change. Fire drill conducted on 8/29/2024.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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 11
Document Has Been Signed on 12/26/2024 02:31 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 12/26/2024 at 01:18 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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in one of of one, no carbon monoxide detector observed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee to install a Carbon Monoxide dictator.
Type A
Section Cited
CCR
87303(a)(1)
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in one of of one bathroom observed to have odor and leaking from the toilet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee agrees to schedule a repairs/ service and submit proof of service by due date. Once completed licensee will submit receipt/invoice of repairs.
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: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 12/26/2024 02:31 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 12/26/2024 at 01:18 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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in 1 out of 1 bathroom observed without Non-skid mats or strips, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee agrees to place non-skid mats or install non-skid strips and submit pictures by due date.
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 3 out of 3 areas, Bleach, bug spray, and tools observed unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee locked all items during inspection. POC cleared 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: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 12/26/2024 02:31 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 12/26/2024 at 01:18 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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 1 out of 5 resident files observed without Tuberculosis clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee agrees to obtain proof of TB results and submit to CCLD by due date.
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: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 12/26/2024 02:31 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 12/26/2024 at 01:18 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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 window screens observed to be bent which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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Licensee agrees to replace window screens and submit pictures by due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

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 2 out of 5 residents did not have an Appraisal Needs and service plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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Licensee agrees to completed appraisal and needs service plan for residents and submit copies of documents by due date to CCLD.
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: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
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: BK HOUSE OF GRACE LLC
FACILITY NUMBER: 107209086
VISIT DATE: 12/26/2024
NARRATIVE
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Deficiencies are being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.


LPA is requesting the following documents be submitted to the Fresno CCL office by 01/02/2025: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

Exit interview conducted and a Plan of Correction was reviewed and developed with Licensee. A copy of this report was discussed and provided to Licensee, Balwinder Kaur, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC809 (FAS) - (06/04)
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