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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209332
Report Date: 08/12/2024
Date Signed: 08/12/2024 04:17:20 PM

Document Has Been Signed on 08/12/2024 04:17 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:LEGACY ADULT CARE LLCFACILITY NUMBER:
107209332
ADMINISTRATOR/
DIRECTOR:		MAKARYAN,HRIPSIMEFACILITY TYPE:
740
ADDRESS:2348 E HARVARD AVENUETELEPHONE:
(559) 293-3955
CITY:FRESNOSTATE: CAZIP CODE:
93703
CAPACITY: 6CENSUS: 6DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:44 AM
MET WITH:Administrator Hripsime MakaryanTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 8/12/24 Licensing Program Analysts (LPA) K. Kaur and J. Leffall arrived unannounced to conduct an Annual Inspection. LPAs introduced themselves, stated the purpose of the visit, and were allowed entry by staff Kelly Gordon. Staff contacted Administrator Hripsime Makaryan who arrived a short while later. 4 clients were present during inspection.

LPAs toured facility with staff. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. During living room tour, LPA’s observed fireplace without a screen. Cleaning chemicals was observed stored and locked closet next to entry door. Fire extinguisher was observed with a service date of: 6/7/24. Fire drill last completed on 5/23/24. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. Inside bathroom toured and observed to be operational. LPAs observed grab bars next to toilet and in shower. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seating and shaded area under patio. LPA’s observed a portable built bathroom next to patio in backyard at 12:18 PM. Toilet observed without grab bars. During medication and MARS review, LPAs observed Centrally Stored Medication and Destruction Record (CSMDR) was incomplete. Medications were checked and observed kept locked in closet in the kitchen. Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ files reviewed to have all the required documents. Staff files were reviewed and observed to have all the required documents.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Deficiencies are as follows: Outside Portable built bathroom without obtaining building permit, fireplace without screen, Centrally Stored Medication and Destruction Record incomplete, and missing grab bars in portable bathroom.

Continued to 809C
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
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 08/12/2024 04:17 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 08/12/2024 at 03:11 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: LEGACY ADULT CARE LLC
FACILITY NUMBER: 107209332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

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 outside bathroom observed without grab bars which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee will install grab bars in portable built bathroom in backyard before residents use.
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 had a portable bathroom built in backyard next to the patio without permit or notifying CCLD which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator will provide statement of intent to apply for permit and provide documentation when submitted. Outside toilet cannot be used until permit is acquired. Administrator to submit a waiver addressing privacy, cleanliness, and health and safety concern.
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: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 08/12/2024 04:17 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 08/12/2024 at 03:11 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: LEGACY ADULT CARE LLC
FACILITY NUMBER: 107209332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

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 Fireplace observed without a screen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator to purchase screen and submit purchase receipt 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: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 08/12/2024 04:17 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 08/12/2024 at 03:11 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: LEGACY ADULT CARE LLC
FACILITY NUMBER: 107209332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

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, record review, the licensee did not comply with the section cited above in 1 out of 2 residents medican was not logged in Centrally stored medication and destrucation record (CSMDR), and some records were incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Administrator to provide in service training on medication record keeping requirements.
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: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


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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: LEGACY ADULT CARE LLC
FACILITY NUMBER: 107209332
VISIT DATE: 08/12/2024
NARRATIVE
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LPA is requesting the following documents be submitted to the Fresno CCL office by 8/19/2024: 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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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