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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209378
Report Date: 11/03/2023
Date Signed: 11/03/2023 11:37:59 AM

Document Has Been Signed on 11/03/2023 11:37 AM - 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 III, LLCFACILITY NUMBER:
107209378
ADMINISTRATOR:HOLLAND, PAULETTEFACILITY TYPE:
740
ADDRESS:85 W ATHENS AVE.TELEPHONE:
(559) 940-7065
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 0DATE:
11/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Paulette HollandTIME COMPLETED:
12:00 PM
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On 11/03/23, Licensing Program Analyst (LPA) K.Kaur conducted an announced Pre-licensing and Component III inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensee Paulette Holland. LPA toured facility with Licensee.

The facility is a 3 bedroom and 2-bathroom home. Fire clearance was granted for 1 non-Ambulatory for total of 6 capacity and one bedridden client in the master bedroom.

The facility was observed to be at a comfortable temperature of 73 degrees F, furnished with adequate seating. A fire extinguisher was observed and has a service date of 04/17/2023. Medications will be kept locked in a cabinet in the living room/dining area. Kitchen was toured and observed to have dishes, plates, and utensils. Knives were observed to be locked and secured in the cabinets near the eating nook. Cleaning chemicals was observed stored and locked in under kitchen counter. LPA observed an extra supply of bed linens and personal hygiene products in hallway closet. Bedrooms were observed to have required furnishings aside from chairs for each resident. All bathrooms toured and were operational during inspection. LPA observed bathroom with securely fastened grab bars and non-skid mat. Toilets are missing grab bars or raised toilet seat with handles. Hot water measured at 122.4 F in the bathroom sink. Washer and dryer observed in laundry room. Outside of facility toured and observed with seating under patio area. LPA observed side gate to be self-closing that needed to be lifted up to open. Carbon monoxide and smoke detectors were tested and observed to be operational. First aid kit not observed. The Licensee has not met all Pre-Licensing requirements.

The following will need to be brought into compliance:
1. Establishment and posting of the facility’s policy regarding theft and investigative procedures
2. 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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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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: ATTENTIVE SENIOR CARE III, LLC
FACILITY NUMBER: 107209378
VISIT DATE: 11/03/2023
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3. Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used.
4. Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.
5. Night lights shall be maintained in hallways and passages to nonprivate bathrooms.
6. Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public.
7. Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475). The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility
8. The text of this section with the heading “Rights of Resident Councils” shall be posted in a prominent place at the facility accessible to residents, family members, and resident representatives.
9. Family councils shall be provided adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, information, and newsletters.
10. complete first aid kit shall be maintained
11. 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 degree C) and not more than 120 degree F (49 degree C)

Due to corrections needing to be made the Pre-Licensing was not passed and Component III was not completed. No deficiencies cited during today’s visit.

Exit interview completed with Licensee and a copy of this report was printed and provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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