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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209377
Report Date: 10/17/2024
Date Signed: 10/18/2024 08:25:59 AM

Document Has Been Signed on 10/18/2024 08:25 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:BURLINGTON, THEFACILITY NUMBER:
157209377
ADMINISTRATOR/
DIRECTOR:		BELL, ASHLEYFACILITY TYPE:
740
ADDRESS:13 SYCAMORE DRTELEPHONE:
(415) 810-0145
CITY:WOFFORD HEIGHTSSTATE: CAZIP CODE:
93285
CAPACITY: 21CENSUS: 13DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:House Manager Stacey Smith and Licensee Anthony BarbatoTIME VISIT/
INSPECTION COMPLETED:
04:00 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 10/17/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit, and met with Designee Stacey Smith. Licensee (L1) arrived during inspection. All 13 residents were present during inspection. LPA toured facility with L1.

The facility was observed to be at a comfortable temperature. The facility was observed clean, and no passageway obstructions or fire hazards were observed inside or outside. Outside of facility toured and observed to be free of debris. Adequate outside seatings were observed available for residents.

A sample of resident and staff files were reviewed to have all the required documents. An adequate supply of perishable and non-perishable food was observed. Walk in refrigerator temperature maintained at 32 degrees F. Cleaning chemicals observed stored and locked under kitchen counter.

Washer and dryer was located in detached building. LPA observed washer and dryer operational during inspection. Medications observed kept locked in medication cart in the medication room. Fire extinguisher was observed throughout the facility with a service date of 05/06/24.

All bedrooms were observed to have required furnishings with adequate lighting and at comfortable temperature. Carbon monoxide and smoke detectors were tested and observed in each bedroom. Bathrooms observed with grabbed bars and non-skid mat. Toilet observed good repair and operational. Bathroom hot water temperature was tested at 112.6 degrees F in bathroom 1, 110.4 degrees F in bathroom 2, and 116.2 degrees F in bathroom 3.

At approximately 1:35PM, LPA and L1 observed a shovel outside room 6 patio unlock. At approximately 1:48PM, LPA and L1 observed a tool set and automatic screwdriver stored in between the kitchen counter unlock. LPA and L1 observed a hole in the wall under kitchen sink.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 4
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: BURLINGTON, THE
FACILITY NUMBER: 157209377
VISIT DATE: 10/17/2024
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
A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 10/23/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability, and control of property. A copy of this report and appeal rights was provided to Licensee, .
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/18/2024 08:26 AM - It Cannot Be Edited


Created By: Mai Yang On 10/17/2024 at 02:54 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: BURLINGTON, THE
FACILITY NUMBER: 157209377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 (f)(1) 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when LPA and Licensee observed at approximately 1:35PM, a shovel placed against the facility wall outside room 6 patio. At approximately 1:48PM, LPA and L1 observed a tool set and automatic screwdriver stored in between the kitchen counter unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
1
2
3
4
Licensee immediately removed the shovel, tool set, and automatic screwdriver and stored it in locked detached building. POC cleared during visit.
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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/18/2024 08:26 AM - It Cannot Be Edited


Created By: Mai Yang On 10/17/2024 at 02:58 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: BURLINGTON, THE
FACILITY NUMBER: 157209377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 and L1 observed at approximately 1:50PM, a hole in the wall under kitchen sink, which poses a potential health, safety or personal rights risk to person in care.
POC Due Date: 11/01/2024
Plan of Correction
1
2
3
4
Wall under kitchen sink shall be repair and proof of repaired shall be submitted to the department by POC due date 11/01/24.
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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4