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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209331
Report Date: 07/24/2024
Date Signed: 07/24/2024 08:31:24 PM

Document Has Been Signed on 07/24/2024 08:31 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:ASPIRING CARE FACILITY, INCFACILITY NUMBER:
107209331
ADMINISTRATOR/
DIRECTOR:		VOSKANYAN, MARINEFACILITY TYPE:
740
ADDRESS:3251 WEST ELLARY AVETELEPHONE:
(559) 241-9332
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 1DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:46 PM
MET WITH:Licensee/ Administrator; Marine Voskanyan TIME VISIT/
INSPECTION COMPLETED:
08:45 PM
NARRATIVE
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On 07/24/2024 Licensing Program Analysts (LPAs) K. Kaur and M. Vega arrived at facility unannounced to complete an annual inspection. LPAs introduced self, stated the purpose of the visit, and was granted entry to the facility by Licensee/ Administrator, Marine Voskanyan.

The facility has 1 resident, who was present during the inspection. LPAs toured the facility with the administrator. Facility is maintained at a comfortable temperature, clean and in good repair. LPA observed Facility required postings on entry wall. Living room is equipped with adequate sofas and recliners for seating. LPAs toured 5 resident rooms and 1 staff room. Residents' bedrooms were observed to be adequately furnished with bed, dresser, chair and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available in the hallway closet. LPAs observed grab bars installed by toilet and shower, non-skid mats in place. At 1:43 pm LPAs did not observe "No Smoking-Oxygen" signage on residence bedroom door. Fire extinguisher was observed to be serviced on 6/6/2024. Tour continued to kitchen, a 7-day supply of non-perishable foods and 2-day supply of perishable foods was observed. The dining room is equipped with table and chairs. At 2:12 PM LPAs observed staff medication on the kitchen counter. 2:03 PM LPAs observed unlocked chemicals and cleaning supplies in laundry room cabinet. LPAs toured garage and observed stored equipment. LPAs observed Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) in dining area. LPAs observed fencing around pool. Backyard gate is self-closing and self-latching. Covered patio and seating observed with adequate outside space for rest and recreational. Smoke alarm and Carbon monoxide detectors installed and operational.

Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report and ID Documentation. At 3:30 PM during Medication review LPAs observed Licensee did not complete the Centrally Stored Medication and destruction record. Staff files were reviewed for good health. Staff files had health screenings/ TB Clearance. It was verified that current staff on duty are CPR certified. Last Fire Drill conducted on 1/03/2024.

Continued to 809C...
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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 07/24/2024 08:31 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/24/2024 at 06:36 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: ASPIRING CARE FACILITY, INC
FACILITY NUMBER: 107209331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 R1's medication was not logged in the LIC 622 Centrally Stored Medication And Destruction Record (CSMDR), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee to log all medication into LIC 622 Centrally Stored Medication And Destruction Record (CSMDR) and submit documented proof by due date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 1 out of 1 LPAs did not observe "No Smoking-Oxygen in use" signage on residence bedroom door, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee to obtain and place signage, and submit pictures 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: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2024 08:31 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/24/2024 at 06:54 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: ASPIRING CARE FACILITY, INC
FACILITY NUMBER: 107209331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(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 staff medication on kitchen counter that were unlocked and accessible to residents in care and chemicals in laundry room was unlocked, 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 removed medication, stored and locked immediately. Licensee removed chemicals to locked area.
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: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
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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: ASPIRING CARE FACILITY, INC
FACILITY NUMBER: 107209331
VISIT DATE: 07/24/2024
NARRATIVE
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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 7/31/2024: 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 Licensee. Report signed on-site; a copy of this report, 809D with appeal rights was provided via email due to technical difficulties.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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