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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209370
Report Date: 09/17/2024
Date Signed: 09/17/2024 04:11:06 PM

Document Has Been Signed on 09/17/2024 04:11 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CHATEAU JESADEANFACILITY NUMBER:
107209370
ADMINISTRATOR/
DIRECTOR:		ROYCHOUDHURY, MINAKSHIFACILITY TYPE:
740
ADDRESS:5633 N MAROA AVENUETELEPHONE:
(559) 499-8229
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 6DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:09 PM
MET WITH:Administrator, Shailesh PatelTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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On 09/17/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit, requested to meet with the Administrator, and was granted entry to the facility. LPA met with Administrator, Shailesh Patel.

LPA reviewed resident and personnel records. LPA found that 2 out of 2 residents receiving hospice services do not have hospice care plan on file. Upon review of personnel files, LPA found that S1 did not have a file on site and S2 did not have a health screen on file.

LPA conducted a tour of the facility with Administrator. LPA toured the facility kitchen. The kitchen appeared to be clean and safe for food preparation. LPA observed an adequate food supply. Knives are kept locked and inaccessible to clients in care, in a cabinet above the stove. The fire extinguisher was observed and was last serviced on 04/10/2023. Resident bedrooms were toured and observed to have the required furnishings. Resident bathrooms were toured and found to be operational during the inspection. Hot water measured at 122.7 degrees F. Common areas were observed to be furnished with adequate seating and lighting. All passageways were clear from obstructions. The facility appeared to be clean and odor free. Smoke detector and carbon monoxide detector observed to be operational.

Exterior tour conducted. LPA did not observe any fire clearance issues during today's inspection. Side gate was observed to be self-latching.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report was discussed and provided to Administrator, Shailesh Patel, whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/01/2024: 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
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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 4
Document Has Been Signed on 09/17/2024 04:11 PM - It Cannot Be Edited


Created By: Alexandria Walton On 09/17/2024 at 03:47 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: CHATEAU JESADEAN
FACILITY NUMBER: 107209370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 when hot water measured at 122.7 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for the above section are met to the Fresno CCL office by the POC due date. The written statement shall include the facility's plan to measure and document the water temperature for 1 week and submit the water log to the Fresno CCL office by 09/26/2024.
Type A
Section Cited
CCR
87405(d)(2)
87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations

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 when the fire extinguisher was last serviced on 04/10/2023, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Licensee agrees to have the fire extinguisher serviced and submit proof of service to the Fresno CCL office by the POC 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/17/2024 04:11 PM - It Cannot Be Edited


Created By: Alexandria Walton On 09/17/2024 at 03:47 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: CHATEAU JESADEAN
FACILITY NUMBER: 107209370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in when S1 did not have a file on site and S2 did not have documentation on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87412 are met to the Fresno CCL office
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when the facility did not have a hospice care plan for 2 out of 2 residents receiving hospice services, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee agrees to obtain a copy of the hospice care plan for 2 out of 2 residents and submit the care plans to the Fresno CCL office by the POC 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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