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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209325
Report Date: 06/07/2024
Date Signed: 06/07/2024 12:28:40 PM

Document Has Been Signed on 06/07/2024 12:28 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:SAVANNA ASSISTED LIVING LLCFACILITY NUMBER:
157209325
ADMINISTRATOR/
DIRECTOR:		FE VILLA-TUNGPALANFACILITY TYPE:
740
ADDRESS:9013 STATEN ISLAND DRTELEPHONE:
(661) 889-6948
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 4DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Licensee Sarah Mazibuko TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 06/07/24, Licensing Program Analysts (LPA) M. Yang arrived unannounced to conduct an annual visit. LPAs introduce self, stated the purpose of the visit and request to meet with Administrator. LPA met with caregiver Maricar Pintor. Licensee Sarah Mazibuko was called and arrived shortly during tour. All four resident was 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 or outside. Medications observed kept locked in kitchen shelf. MARs were reviewed. Fire extinguisher was observed with a purchased date of: 03/20/2024. Temperature maintained for refrigerator at 30 degrees F and freezer at 0 degrees F. An adequate supply of perishable and non-perishable food was observed. Cleaning supplies observed locked under kitchen sink and garage cabinet. All bedrooms were observed to have required furnishings and with adequate lightening. Bathrooms were properly equipped and operational. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested range 106.3 degrees F in bathroom 1 and range at 106.3 and 105.9 degrees F in shared bathroom. Outside of facility toured and observed to be free of debris. Side gate observed self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. All residents’ file reviewed to have all the required records. Staff files were observed to have current First Aid/CPR.

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: 06/14/24.
Forms requested: Lic 308, Lic 500, Lic 610E, and current liability insurance. A copy of this report and appeal rights was provided to the Licensee, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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 06/07/2024 12:28 PM - It Cannot Be Edited


Created By: Mai Yang On 06/07/2024 at 12:16 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: SAVANNA ASSISTED LIVING LLC
FACILITY NUMBER: 157209325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1796.45
Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA reviewed and observed S1 did not have a TB result on file which poses a potential risk to the health and safety of the residents.
POC Due Date: 06/14/2024
Plan of Correction
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Licensee shall ensure all staff have a TB result on file. S1 TB result shall be submitted to the Fresno CCL office by POC due date 6/14/24.
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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
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