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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209191
Report Date: 12/11/2024
Date Signed: 12/11/2024 03:34:18 PM

Document Has Been Signed on 12/11/2024 03:34 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:WESTCHESTER HOME ON SPRUCE, THEFACILITY NUMBER:
157209191
ADMINISTRATOR/
DIRECTOR:		KAUR, LAKHWINDERFACILITY TYPE:
740
ADDRESS:2485 SPRUCE STREETTELEPHONE:
(661) 633-1225
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Administrator Sundae HillTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 12/11/24, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced subsequent complaint investigation and met with Administrator Sundae Hill.

During the course of the complaint investigation, interviews were conducted and residents’ medications were checked. Centrally Stored Medication Record and Medications Administration Record (MAR) was reviewed.

Technical Support Program (TSP) assistance was offered to Administrator. Administrator will make a decision and reach out the department regarding acceptance.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6. An exit interview was conducted. A copy of this report and appeal rights were provided to Administrator, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 12/11/2024 03:34 PM - It Cannot Be Edited


Created By: Mai Yang On 12/11/2024 at 01:47 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: WESTCHESTER HOME ON SPRUCE, THE
FACILITY NUMBER: 157209191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2024
Section Cited
CCR
87465(h)(5)

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87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement was not met as evidenced by:
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The five small capsule was immediately removed by Administrator. Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation which will include ensuring that all medications are stored in original container with no other medications. Statement will submit to Fresno CCL office by POC due date 12/12/24.
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Based on observation, LPA checked R1’s medication with Administrator present. LPA observed in R1’s Furosemide 20 mg medication bottle, 5 capsule that were different size stored in with the Furosemide tablets which poses an immediate health, safety or personal rights risk to persons in care.
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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: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/11/2024 03:34 PM - It Cannot Be Edited


Created By: Mai Yang On 12/11/2024 at 01:48 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: WESTCHESTER HOME ON SPRUCE, THE
FACILITY NUMBER: 157209191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2024
Section Cited
CCR
87465(h)(6)

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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 was not met as evidenced by:
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Licensee shall ensure that all residents have Lic 622 on file and up to date. Copy of Lic 622 for all 4 residents will be submitted to Fresno CCL by POC due date 12/17/24.
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Based on interviews conducted and records reviewed, there are no Centrally Stored Medication Record (Lic 622) on file for all four residents, which poses/ posed a potential health, safety, or personal rights risk for the person in care.
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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: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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