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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206712
Report Date: 09/20/2024
Date Signed: 09/23/2024 09:43:27 AM

Document Has Been Signed on 09/23/2024 09:43 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:COMFORT CARE HOME IIIFACILITY NUMBER:
157206712
ADMINISTRATOR/
DIRECTOR:		DHILLON, AMARDEEP (AMY)FACILITY TYPE:
740
ADDRESS:9609 GHIRARDELLI DRTELEPHONE:
(661) 858-0434
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 6DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Licensee/ Administrator Amy DhillonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 09/20/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met caregiver Myrna Agatep. LPA toured facility with caregiver. Licensee/Administrator Amy Dhillon was called and arrived shortly and unable to stay for inspection. Licensee authorized caregiver to sign report. All six residents were present during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Fire extinguisher was observed with a service date: 03/07/2024. Last fire drill completed on 08/03/24 An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 39 degrees F and freezer at 0 degrees F. Cleaning supplies and chemicals stored and locked under kitchen sink and in garage cabinet. Medications were observed locked in laundry room shelf. MARs were reviewed. Extra linens were observed in hall closet. All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested at 116.2 and 118 degree F in the master bathroom and 115.8 degree F in bathroom 1. Outside of facility toured and observed to be free of debris. Adequate outdoor seatings available for residents. Side gate observed self-latching and self-closing. Half of the residents’ file and a sample of staff files were reviewed. Carbon monoxide and smoke detector observed operational during visit.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 9/26/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, and control of property. A copy of this report was emailed to Licensee as requested.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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 09/23/2024 09:43 AM - It Cannot Be Edited


Created By: Mai Yang On 09/20/2024 at 11:27 AM
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: COMFORT CARE HOME III
FACILITY NUMBER: 157206712

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, LPA observed R1’s Insulin medication stored the garage refrigerator unlock which poses an potential health and safety risk to the residents.
POC Due Date: 09/21/2024
Plan of Correction
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Licensee shall ensure that all medications shall be locked and inaccessible to residents in care. Proof of medications
removed and locked, inaccessible to residents shall be submitted to the department by POC due date 09/21/24.

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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
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