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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209363
Report Date: 12/19/2024
Date Signed: 12/19/2024 02:24:43 PM

Document Has Been Signed on 12/19/2024 02:24 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:DEVOTED HEARTS SENIOR CARE HOME LLCFACILITY NUMBER:
157209363
ADMINISTRATOR/
DIRECTOR:		JACKSON, LETICIAFACILITY TYPE:
740
ADDRESS:10311 RIO DEL MAR DRIVETELEPHONE:
(661) 735-7308
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 5DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Licensee/Administrator Leticia Jackson TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 12/19/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met with staff Sonia Bautista. Licensee/Administrator Leticia Jackson was called and arrived shortly. All five residents were present during inspection. Residents were observed in the common area and in the bedrooms. LPA toured facility with Licensee.

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. All residents’ bedroom were toured and observed to have the required furnishings and with adequate lightening. At 10:24AM, medications were observed on side table and television stand in room 1 unlock. At 10:29AM, medications and alcohol bottle were observed in room 2 closet unlock. Alcohol bottle was observed in staff closet in living room unlock.

Fire extinguisher was observed with a service date: 01/18/24. LPA toured kitchen and observed cleaning chemical stored under kitchen counter unlock. Discontinued medications were observed stored under kitchen counter next to stove unlock.
An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 32 degrees F and freezer at -3 degrees F.

Washer observed operational during visit. At 10:51AM, LPA observed a large box fill with cleaning bottles stored in the garage unlock. Refrigerated medications were observed in mini refrigerator unlock in the garage next to large chemical box. Knives were observed stored in a metal cabinet in the garage unlock. Paint cans were observed in the garage back wall unlock.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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: DEVOTED HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 157209363
VISIT DATE: 12/19/2024
NARRATIVE
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The bathrooms were toured. Non-skid mat and grabbed bars were observed. Hot water temperature was tested at 114.9 degree F in the bathroom 1 and range at 110.8 and 111.4 degree F in master bathroom. Extra linens were observed.

Outside of facility toured and observed to be free of debris. Side exit observed self-closing and self-latching. Adequate outdoor seatings available for residents. Medications were observed locked in cabinet in common area. Residents’ MARs and medications were checked. Sample of residents’ and 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 requested to be updated and submitted to Fresno CCL by 12/26/24: Lic 308, Lic 500, Lic 610E, Lic 9282, current liability insurance, and Administrator certificate. 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: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/19/2024 02:24 PM - It Cannot Be Edited


Created By: Mai Yang On 12/19/2024 at 01:36 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: DEVOTED HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 157209363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

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
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Based on records review and observation, staff did not administer 3 out of 4 medications for R1 as directed by
physician and staff administered expired medication to R2, which poses an immediate health and safety risk for the person in care.
POC Due Date: 12/20/2024
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 12/20/24.

Licensee shall have all staff retrained on medication training which include administering medications and review medications. Licensee will submit documentation of training topics with staff attendance rooster to the Fresno CCL office by 01/02/25.
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 medications unlock in room 1, room 2, and in the garage mini refrigerator, which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee immediately removed the medications in room 1 and 2 and locked it in kitchen shelf. Licensee immediately lock garage mini refrigerator. 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: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/19/2024 02:24 PM - It Cannot Be Edited


Created By: Mai Yang On 12/19/2024 at 01:38 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: DEVOTED HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 157209363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

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 kitchen counter, staff closet, and in garage unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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L1 immediately removed chemicals off the premises. POC cleared during visit.
Type A
Section Cited
CCR
87465(h)(6)
87465(h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation and record review, licensee did not comply with the section cited above when R2’s Aller-zyrs Cetrizine 10 mg was not logged in centrally stored list which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee shall ensure that all resident’s medications that are centrally stored are record in the facility. Licensee to submit copies of Centrally Stored Medication Record (Lic 622) for R1 to CCL by POC due date 12/20/24.
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: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


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Document Has Been Signed on 12/19/2024 02:24 PM - It Cannot Be Edited


Created By: Mai Yang On 12/19/2024 at 01:39 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: DEVOTED HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 157209363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(i)
87465(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, destructed medications for residents for former residents and current residents were observed stored under kitchen counter no processed to be disposed and destroyed, which poses a potential health, safety or personal rights risk to person in care
POC Due Date: 12/27/2024
Plan of Correction
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Licensee shall ensure that all medications being disposed shall be documented and destroyed according to procedures. Proof of disposed medications documented and destroy per procedure shall be submitted the department by POC due date 12/27/24.
Type B
Section Cited
HSC
1796.45
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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Based on records review, S1 and S2 did not have a TB result on file which poses a potential risk to the health and safety of the residents.
POC Due Date: 01/08/2025
Plan of Correction
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Licensee shall ensure all staff have a TB result on file prior or within 7 days after employment. S1 and S2 TB result shall be submitted to the Fresno CCL office by POC due date 01/08/25.
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: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


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