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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208962
Report Date: 06/21/2024
Date Signed: 06/24/2024 02:49:48 PM

Document Has Been Signed on 06/24/2024 02:49 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:ARCADIA GARDENS RESIDENTIAL CARE IVFACILITY NUMBER:
157208962
ADMINISTRATOR/
DIRECTOR:		ROURA, OLIVIAFACILITY TYPE:
740
ADDRESS:12301 RIVERFRONT PARK DRIVETELEPHONE:
(661) 412-7042
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 5DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Licensee Olivia Roura TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 6/21/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a Annual visit. LPA introduced self, stated the purpose of the visit, and was greeted by staff Felimon Mangoagui. Licensee (L1) Olivia Roura was called and arrived shortly. LPA toured facility with L1 toured facility with staff. All five residents were present during inspection sleeping.

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. Medications are kept locked in hall closet. LPA audit medications and reviewed MARs. Fire extinguisher was observed with a service date of 04/04/24. An adequate supply of perishable and non-perishable food was observed. Temperature observed refrigerator maintain a 40 degrees F and freezer temperature at 0-degree F. At approximately 02:11 PM, LPA observed cleaning chemicals stored under kitchen sink unlock. LPA toured all resident’s bedrooms. Resident rooms observed to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms were properly equipped, and the hot water temperature was tested at 110.8 degrees F in bathroom 1 and 110.1 degrees F shared master bathroom. Outside of facility toured. Side gate was self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. A sample of resident and staff files were reviewed.

A deficiency and an immediate Civil Penalty of $1000 was assessed. See Lic 421BG is being cited on the
attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following updated forms were requested to be submitted to Fresno CCL by 06/27/24: Lic 308, Lic 500, Lic 610E, and current liability insurance. A copy of this report and appeal rights was provided to Licensee.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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 06/24/2024 02:49 PM - It Cannot Be Edited


Created By: Mai Yang On 06/21/2024 at 03:50 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: ARCADIA GARDENS RESIDENTIAL CARE IV
FACILITY NUMBER: 157208962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and observation, the licensee did not comply with the section cited above. LPA audit resident’s medications and reviewed resident’s MARS; observed three of the R1’s medications were not administered as directed by physician which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 06/22/2024
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 06/22/24.
Type A
Section Cited
CCR
87465(h)(1)
87465 (h)(1) Medications shall be centrally stored…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and observation, the licensee did not comply with the section cited above. R2’s medication Acidophilus prescribed by the physician was not observed centrally stored which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 06/22/2024
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation and proof R2’s medications is centrally stored in the facility shall be submitted to Fresno CCL office by POC due date 06/22/24.
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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/24/2024 02:49 PM - It Cannot Be Edited


Created By: Mai Yang On 06/21/2024 at 03:58 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: ARCADIA GARDENS RESIDENTIAL CARE IV
FACILITY NUMBER: 157208962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(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 when LPA observed at approximately 02:11PM three resident was sitting in the living when LPA observed multiple cleaning chemicals stored under kitchen sink unlocked while three resident accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2024
Plan of Correction
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Staff immediately locked chemicals. POC cleared during visit.
Type A
Section Cited
CCR
87465(h)(6)
87465 (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews conducted, observation, and records reviewed, the licensee did not comply with the section cited above. Two of R2’s medication prescribed by physician; Biascody 10 mg Suppository and Acetaminophen 325mg was not documented in the resident’s MARs which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 06/22/2024
Plan of Correction
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Licensee agrees to update resident records to ensure each client. A complete record is to be submitted to Fresno CCL by the POC due date 06/22/24.
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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/24/2024 02:49 PM - It Cannot Be Edited


Created By: Mai Yang On 06/21/2024 at 04:51 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: ARCADIA GARDENS RESIDENTIAL CARE IV
FACILITY NUMBER: 157208962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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S1 and S2 are fingerprinted cleared not associated to facility provided resident care and supervision which poses an immediate risk to the health and safety of the residents.
POC Due Date: 06/22/2024
Plan of Correction
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S1 and S2 was removed from the facility immediately. S1 and S2 is not permitted back until associated. Licensee is to submit LIC 9182 Fingerprint transfer request for S1 and S2 to Fresno CCL office by POC due date 06/22/24.

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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
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