<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209299
Report Date: 01/21/2025
Date Signed: 01/21/2025 05:31:31 PM

Document Has Been Signed on 01/21/2025 05:31 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:LERWICK HOME CAREFACILITY NUMBER:
157209299
ADMINISTRATOR/
DIRECTOR:		TELMO, SOCORRO ANNFACILITY TYPE:
740
ADDRESS:10213 LERWICK AVENUETELEPHONE:
(661) 665-2874
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 6DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Administrator Socorro Ann Telmo TIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/21/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met Licensee/ Administrator (L1) Socorro Ann Telmo. LPA toured facility with L1. All residents were present during inspection of which 3 residents are receiving hospice care. Residents were observed sitting in the common areas and in the bedroom during tour.

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.

An adequate supply of perishable and non-perishable food was observed. At 12:25PM, LPA observed expired perishable foods and snacks in the pantry. Refrigerator temperature is maintained at 36 degrees F and freezer at 0 degrees F. Chemicals were observed locked under kitchen sink. LPA and L1 observed cleaning chemicals stored in garage cabinet unlock. A shovel was observed placed next on the outside of the garage cabinet. A bug spray bottle and car oil bottles were observed stored in the back of the garage unlock. LPA continue toured inside the facility LPA and L1 observed a tool ranch stored unlock in the kitchen drawer. Knives were observed lock under kitchen counter. Medications were observed locked in kitchen shelves. MARs were reviewed and medications were checked.

Fire extinguisher was observed with a service date of: 03/08/24. Last fire drill completed on 01/18/25.

All bedrooms were observed to have the required furnishings and with adequate lightening. Extra linens were observed. The bathrooms were toured and observed operational during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested at 118.6 degree F in the bathroom 1 and 119.3 degree F in bathroom 2.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 7
Document Has Been Signed on 01/21/2025 05:31 PM - It Cannot Be Edited


Created By: Mai Yang On 01/21/2025 at 04:11 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: LERWICK HOME CARE
FACILITY NUMBER: 157209299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the Licensee did not comply with the section cited above when LPA observed a tool ranch in kitchen drawer, bug spray with car oil stored in the back of the garage, a shovel stored next to chemical cabinet, and chemical cabinet in the garage lock was loose and unlock, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
1
2
3
4
Licensee immediately removed shovel off the premises and lock the tool ranch. Staff removed the bug spray and car oil stored into the garage cabinet. Staff immediately tighten lock on garge cabinet. POC cleared during visit.
Type A
Section Cited
CCR
87555(b)(8)
87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state, and local authorities. Good in damaged containers shall not be accepted, used, or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, multiple expired nonperishable food and snacks was observed in pantry, poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
1
2
3
4
Licensee immediately disregarded expired food. 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: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 01/21/2025 05:31 PM - It Cannot Be Edited


Created By: Mai Yang On 01/21/2025 at 04:13 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: LERWICK HOME CARE
FACILITY NUMBER: 157209299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

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
1
2
3
4
Based on records review and observation, staff did not administer R1’s medication Furosemide 20 mg and medication Cephalexin 500 mg as directed by physician. Staff did not administer R2’s medication Atorvastatin 40 mg and medication Amlodipine 10 mg as directed by physician, which poses an immediate health and safety risk for the person in care.
POC Due Date: 01/22/2025
Plan of Correction
1
2
3
4
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 01/22/25.

Type A
Section Cited
CCR
87465(d)(3)
87465(d)(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:

Deficient Practice Statement
1
2
3
4
Based on records review and interviews, staff have administered medications and not documented in the MARs for R1’s medication Furosemide 20 mg, Cephalexin 500 mg, R4 medication Tylenol 325 mg, and R2’s medication Tylenol 650mg in the MARs. Staff confirmed and stated all the residents’ medications were administered on 01/21/25 at 08:00AM and was not record, which poses an immediate health and safety risk for the person in care.
POC Due Date: 01/22/2025
Plan of Correction
1
2
3
4
Licensee immediately documented and record R1’s medication Furosemide, Cephalexin, Tylenol and R2’s medication Tylenol in the MARs. Licensee shall have S1 retrained on medication training which include administering medications, reviewing medications and MAR. Licensee will submit documentation of training materials with staff attendance rooster to the Fresno CCL office by POC due date 01/22/25.
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: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/21/2025 05:31 PM - It Cannot Be Edited


Created By: Mai Yang On 01/21/2025 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: LERWICK HOME CARE
FACILITY NUMBER: 157209299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87455(b)(9)
87455 (b)(9) The following persons may be accepted or retained by the licensee: (9)Persons who have been diagnosed as terminally ill and who have obtained the services of hospice, certified in accordance with federal medicare conditions of participation and licensure, provided the licensee has obtained a facility hospice care waiver in accordance with the provisions of Section 87632, Hospice Care Waiver, and hospice care is being provided in accordance with the provisions of Section 87633, Hospice Care for Terminally Ill Residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records reviewed and observation, the facility has hospice waiver for 2 residents and had obtain 3 residents on hospice care, which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
1
2
3
4
Licensee shall not obtain more than hospice waiver granted. Licensee will request for hospice waiver increase and submitted to the Fresno CCL by POC due date 01/22/25.

Licensee states agree to relocate 1 of the 3 resident receiving hospice care if hospice waiver increase is denied.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 01/21/2025 05:31 PM - It Cannot Be Edited


Created By: Mai Yang On 01/21/2025 at 04:17 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: LERWICK HOME CARE
FACILITY NUMBER: 157209299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in when 1 out of 3 residents whose receiving Hospice care did not have a hospice care plan on file. R3 files were reviewed and confirmed by Licensee that the files did not contain Hospice Plan of care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
1
2
3
4
Hospice care plan for R3 shall be obtained by POC due date 01/31/25.
Type B
Section Cited
CCR
87458(c)(1)(A)
87458(c)(1)(A) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A)Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records reviewed, residents’ files were reviewed, 1 out of 6 residents do not have TB result on file. Licensee confirmed R1 do not have TB results on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

POC Due Date: 02/07/2025
Plan of Correction
1
2
3
4
Licensee will submit proof of TB result for R1 to Fresno CCL by POC due date 02/07/25.
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: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/21/2025 05:31 PM - It Cannot Be Edited


Created By: Mai Yang On 01/21/2025 at 04:19 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: LERWICK HOME CARE
FACILITY NUMBER: 157209299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

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 reports hall 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:
Deficient Practice Statement
1
2
3
4
Based on records review, S1 did not have a good health screening and TB result on file and was confirmed by Licensee, which poses a potential risk to the health and safety of the residents.
POC Due Date: 02/07/2025
Plan of Correction
1
2
3
4
S1 good health screening and TB result shall be submitted to the Fresno CCL office by POC due date 02/07/25.

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: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
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: LERWICK HOME CARE
FACILITY NUMBER: 157209299
VISIT DATE: 01/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Outside of facility toured and observed to be free of debris. Side gate observed self-closing and self-latching. Adequate outdoor seatings available for residents. All residents’ and a sample of staff files were reviewed. Carbon monoxide and smoke detector operational during visit.

Technical Support Program (TSP) assistance was offered to Licensee. Licensee will make a decision and


reach out the department regarding acceptance.

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: 01/27/25. The following updated forms were requested: 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 these report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
Page: 7 of 7