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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209142
Report Date: 08/30/2023
Date Signed: 08/30/2023 01:23:09 PM

Document Has Been Signed on 08/30/2023 01:23 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:OAKHURST BOARD AND CAREFACILITY NUMBER:
207209142
ADMINISTRATOR:LEANG, LUCYFACILITY TYPE:
740
ADDRESS:41456 PAMELA PLACETELEPHONE:
(559) 293-3174
CITY:OAKHURSTSTATE: CAZIP CODE:
93644
CAPACITY: 11CENSUS: 5DATE:
08/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Caregiver- Nary NewhillTIME COMPLETED:
01:45 PM
NARRATIVE
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LPA arrived to the facility unannounced to conduct a case management and was greeted by Caregiver Nary Newell. LPA explained the reason for the visit and asked staff to contacted Administrator Lucy Leang to inform the Dept. was at the facility. Caregiver Nary had contacted the 2 Care Coordinators. LPA attempted to contact Administrator Lucy but was unsuccessful.
When LPA first arrived there was a resident sitting outside by himself, and the front door did not have an auditory device. Facility has 9 bedrooms and 4 bathrooms. Facility currently has 5 residents, 2 which are dementia residents.

While touring the facility LPA observed scissors in a cup on the counter top which are accessible to residents.
While LPA toured the outside of the facility there was a gas container accessible to residents in the back of the facility.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Caregiver Nary Newell.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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 08/30/2023 01:23 PM - It Cannot Be Edited


Created By: Brianna Miranda On 08/30/2023 at 01:08 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: OAKHURST BOARD AND CARE
FACILITY NUMBER: 207209142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2023
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia
(f) 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:
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Scissors were removed and put away inaccessible to residents. Pictures will be sent verifiying gas can has been removed an inaccessible to residents.
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Based on observation & interview the licensee failed to keep scissors and gas can inaccessible to residents in care. This poses an immediate health, safety, or personal rights risk to residents in care.
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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:Brenda Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 08/30/2023 01:23 PM - It Cannot Be Edited


Created By: Brianna Miranda On 08/30/2023 at 01:12 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: OAKHURST BOARD AND CARE
FACILITY NUMBER: 207209142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2023
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
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Owner is going to have maintenance look to see if a wire is not tripped. Owner will verify alarms are working and provide verification to LPA.
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Based on observation & interview the licensee failed to have operating auditory devices to monitor exits. LPA tested front door and side door. This poses potential health, safety, or personal rights risk to residents in care.
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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:Brenda Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
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