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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209266
Report Date: 03/07/2024
Date Signed: 03/12/2024 11:15:44 AM

Document Has Been Signed on 03/12/2024 11:15 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:HEAVENLY CASTLE CARE INCFACILITY NUMBER:
157209266
ADMINISTRATOR:NSHANYAN, HASMIKFACILITY TYPE:
740
ADDRESS:1651 WHITE ROCK RDTELEPHONE:
(310) 993-2447
CITY:FRAZIER PARKSTATE: CAZIP CODE:
93225
CAPACITY: 6CENSUS: 5DATE:
03/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Hasmik NshanyanTIME COMPLETED:
03:00 PM
NARRATIVE
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On 3/7/2024 Licensing Program Analysts (LPAs) B. Miranda and S. Doucette arrived to the facility unannounced to conduct a case management visit. LPAs introduced themselves and explained the reason for the visit. LPAs were allowed entry into the facility and Administrator (AD) Hasmik Nshanyan was contacted via phone. AD stated they were on their way and would arrive in about 45 minutes.

LPAs observed facility to be clean, clutter & odor free. LPAs requested resident files to review while waiting for AD to arrive. Staff told LPAs to wait for AD. Due to staff not complying with LPAs requests to review resident records deficiency was cited.

LPAs observed R1 & R2 in room 1. R1 has full bed rails on bed. LPAs reviewed R1's chart which did not indicate resident was on hospice and did not have a doctor's order on file for full bed rails. Due to facility not having proper documentation for full bed rails deficiency was cited.
Resident records were reviewed. During the review R3's centrally stored log was not current and up to date. After reviewing R3's Oxycodone medication and AD conducting a medication count the start date did not match the medication count deficiencies were cited

All deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 809D.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Hasmik Nshanyan.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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 03/12/2024 11:15 AM - It Cannot Be Edited


Created By: Brianna Miranda On 03/07/2024 at 12:13 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: HEAVENLY CASTLE CARE INC
FACILITY NUMBER: 157209266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
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AD removed the full bed rails from R1's bed.
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Based on observation, interviews, and records reviewed the licensee failed to obtain proper documentation for R1 to have full bed rails on the bed.
This poses an immediate health, safety, or personal rights risk to residents in care.
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POC completed while LPA was in the facility.
Type A
03/08/2024
Section Cited
CCR87465(a)(6)

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
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Administrator will complete log for Oxycodne. Statement will be provided to LPA by due date.
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Based on observation, interviews, and records reviewed the licensee failed to properly log R3's narcotic medication Oxycodone.
This poses an immediate health, safety, or personal rights risk to residents in care.
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POC completed while LPA was in the facility.
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:Brenda Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/12/2024 11:15 AM - It Cannot Be Edited


Created By: Brianna Miranda On 03/07/2024 at 12:15 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: HEAVENLY CASTLE CARE INC
FACILITY NUMBER: 157209266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2024
Section Cited
CCR
87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Administrator will conduct training with staff to provide requested documents/records to LPAs when requested.
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Based on observation, interviews, and records reviewed the licensee failed to provide resident records when LPA’s requested. Staff was asked for resident files to review and told LPAs to wait for the administrator.
This poses a potential health, safety, or personal rights risk to the residents 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:Brenda Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/12/2024 11:15 AM - It Cannot Be Edited


Created By: Brianna Miranda On 03/07/2024 at 01:16 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: HEAVENLY CASTLE CARE INC
FACILITY NUMBER: 157209266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self administered medications as needed.
This requirement is not met as evidenced by:
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Administrator will have Centrally stored log completed timely. Verification will be provided to LPA.
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Based on observation, interviews, and records reviewed the licensee failed to log centrally stored medication indicated medication started on Monday 4/4/24 and after the count indicated the start date was 3/6/24. There was no verifiable date the medication started and the count of R3's Oxycodone was incorrect.
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POC completed while LPA was in the facility.

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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:Brenda Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4