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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209268
Report Date: 12/09/2024
Date Signed: 12/16/2024 10:58:47 AM

Document Has Been Signed on 12/16/2024 10:58 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:PRECIOUS LIFE RESIDENCES, LLCFACILITY NUMBER:
157209268
ADMINISTRATOR/
DIRECTOR:		CRISOSTOMO, PETROFACILITY TYPE:
740
ADDRESS:10414 BICHESTER COURTTELEPHONE:
(661) 472-9253
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 5DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Susan Blanza, LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 12/09/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and requested to meet with Administrator. LPA met with staff John Flores and staff Edward Alfonso. Licensee (L1) Susan Blanza was called and arrived shortly. LPA toured facility with L1. All five 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.

At approximately 11:07AM, LPA observed knives stored under medication cabinet unlock. LPA observed over-the-counter medications single packets stored in First Aid kit on the wall near fire extinguisher. Fire extinguisher was observed with purchased date of 08/09/24. F. At approximately 11:18AM, LPA observed chemicals stored under kitchen sink. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature observed maintained at 37 degrees F and freezer temperature maintained at -2 degrees. LPA observed R1 and R2’s medications stored and refrigerated on the bottom of the refrigerator door unlock.

Medications were observed unlock in medication shelves. MARS was reviewed and medications were checked. LPA observed chemicals, paint, knives stored in garage cabinet unlock. Paint buckets were observed next to water heater in the garage unlock.

Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. At approximately 12:45PM, LPA observed R2 and R4 in bedroom with an alcohol bottle next to television on television stand.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268
VISIT DATE: 12/09/2024
NARRATIVE
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All bathrooms are toured. All bathrooms were observed operating and functioning during inspection. Non-skid mat and grabbed bars were observed. Cleaning chemicals were observed under hall bathroom sink unlock. Hot water temperature was tested at 106.3 degrees F in hall bathroom.

Outside of facility toured. At approximately 1:00PM, a bleach bottle was observed on the floor next to the BBQ grill unlock. Side gate was observed free of debris. Adequate outdoor seating available for residents.

A sample of resident and staff’s files were reviewed. Carbon monoxide and smoke detectors were tested and observed to be operational.

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

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D.

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 12/16/24: Lic 308, Lic 500, Lic 610E, current liability insurance, and control of property. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of these report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2024 10:58 AM - It Cannot Be Edited


Created By: Mai Yang On 12/09/2024 at 02:44 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

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... not accessible to persons other than employees...

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 and Licensee observed residents’ medications stored and unlock in the medication cabinet. Over the counter medications were observed stored in First Aid box unlock on the wall. LPA observed R1 and R2 refrigeration medication was observed stored in the refrigerator unlock which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 12/10/2024
Plan of Correction
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Licensee immediately locked medication cabinet. Licensee shall ensure to have resident’s medication that requires refrigeration lock and inaccessible to residents. Proof of R1 and R2’s refrigeration medication lock shall be submitted to the department by POC due date 12/10/24.
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 review and observation, staff did not administer R1’s medication Cardizem 120 mg as directed by physician, which poses an immediate health and safety risk for the person in care.
POC Due Date: 12/10/2024
Plan of Correction
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Licensee agree to write statement of steps facility will take to ensure regulations is met. Statement will be submitted to Fresno CCL by POC due date 12/10/24.

Licensee shall have all staff retrained on administering medications. Licensee will submit documentation of training topics with staff attendance rooster to the Fresno CCL office by 12/23/24.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/16/2024 10:58 AM - It Cannot Be Edited


Created By: Mai Yang On 12/09/2024 at 02:46 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 checked R1’s medication and observed a different color tablet stored with R1’s Losartan 50mg medication in the medication bottle which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
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 12/10/24.
Type A
Section Cited
CCR
87705(f)(1)
87705 (f)(1) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 knives stored unlock under medication shelf and in in garage cabinet accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 12/10/2024
Plan of Correction
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Staff immediately removed knives into lock shelf. POC cleared during visit.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


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Document Has Been Signed on 12/16/2024 10:58 AM - It Cannot Be Edited


Created By: Mai Yang On 12/09/2024 at 02:51 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

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 cleaning supplies unlock under the kitchen sink and under bathroom sink. At approximately 12:42PM, LPA and L1 observed chemicals stored in garage cabinet unlock. Alcohol bottle was observed on resident television stand unlock in the R3 and R5’s shared room. Cleaning chemicals stored under bathroom sink unlock. A bleach bottle was observed outside next the BBQ grill unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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L1 immediately removed chemicals and cleaning solution to lock laundry shelf. POC cleared during visit.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2024 10:58 AM - It Cannot Be Edited


Created By: Mai Yang On 12/09/2024 at 04:15 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: PRECIOUS LIFE RESIDENCES, LLC
FACILITY NUMBER: 157209268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
87412(a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, S1 and S2 do not have all the required personnel records maintained on file.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee shall ensure all staff have all the required records on file. Licensee will submit Lic 503, Lic 508, and Lic 9052 for S1 and S2 to the Fresno CCL office by POC due date 12/27/24.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


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