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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209288
Report Date: 03/04/2024
Date Signed: 03/05/2024 08:46:14 AM

Document Has Been Signed on 03/05/2024 08:46 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:CAMILA CARE VILLA, LLCFACILITY NUMBER:
157209288
ADMINISTRATOR:PANGILINAN, MARIA EMMAFACILITY TYPE:
740
ADDRESS:10005 COBBLESTONE AVETELEPHONE:
(904) 762-5945
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 5DATE:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Maria Emma Pangilinan, LicenseeTIME COMPLETED:
04:30 PM
NARRATIVE
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On 03/04/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with staff Roderick “Erick” Buan. Licensee(L1) Maria Emma Pangilinan was called and arrived shortly. LPA toured facility with L1. All five residents were present during the 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. Sharps observed locked under kitchen counter. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 40 degrees F and freezer maintained at -4 degree F. Fire extinguisher was observed with a service date of: 12/27/23. Medications were checked and observed kept locked living room closet and kitchen cabinet. Residents’ MARS were reviewed. Cleaning chemicals observed locked in laundry room. Washer and dryer observed operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested 114.4 degrees F. in bathroom 1 and range between 117.1 and 118.5 degrees F in master bathroom. Outside of facility toured and observed free of debris. Side gate was self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. All resident and reviewed to have all the required documents. Four staff files reviewed to have current 1st Aid/CPR, medical training, fingerprinted cleared and associated.

A deficiency is being cited on the attached 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: 03/11/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, and current liability insurance. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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 03/05/2024 08:46 AM - It Cannot Be Edited


Created By: Mai Yang On 03/04/2024 at 03:23 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: CAMILA CARE VILLA, LLC
FACILITY NUMBER: 157209288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411(F) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when LPA reviewed S1 file and observed no health screening were on file, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Licensee will submit proof of S1’s health screening to CCL by POC due date 3/18/24.

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: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024


LIC809 (FAS) - (06/04)
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