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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209199
Report Date: 12/05/2024
Date Signed: 12/05/2024 05:20:16 PM

Document Has Been Signed on 12/05/2024 05:20 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:AT HAVEN HOME IIFACILITY NUMBER:
247209199
ADMINISTRATOR/
DIRECTOR:		BURNS, JASMINFACILITY TYPE:
740
ADDRESS:3763 N LAKE ROADTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY: 13CENSUS: 12DATE:
12/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:46 PM
MET WITH:House Manager, Myra TIME VISIT/
INSPECTION COMPLETED:
05:28 PM
NARRATIVE
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On 12/5/24 Licensing Program Analysts (LPAs) M. Garza and L. Salazar arrived at facility for an unannounced case management. LPAs met with Direct Care Staff, Teny Daraphet, explained reason for visit and was permitted entry into the facility. Administrator, Jasmin Burns and House Manager, Myra Torres arrived a short time later.

This case management visit is being conducted due to observations made during an initial complaint visit on 12/05/2024. The following issues were observed during visit:
  • Room 10 observed with hole behind door in need of replacement
  • Clutter in garage in need of removal
  • Refrigerator in garage in need of cleaning/repair
  • Food source is not the required 2-day perishable/7-day non-perishable
  • Food source in kitchen cupboard observed to be expired
  • Screws observed near top of cupboard storing food appearing to be secured
  • Medications/items observed unlocked/accessible in kitchen cupboard, kitchen refrigerator, in R6 closet and hallway cupboard
  • Hood vent observed open and in need of repair under kitchen cupboard
  • Bottom kitchen cupboard door broken and in need of repair/replacement
  • Food not properly stored/dated in refrigerator
  • Bedframe for R9/room 9 observed on floor
  • R11 observed with scissor on TV tray unsecured and accessible to residents in care
  • R1's window observed locked with board preventing from opening
  • R1's exit door observed with a lock at the top and blocked with chair preventing from exiting
  • Front door observed broken and not properly latching
  • Front door observed with lock at bottom of door
  • PUB 475 observed inappropriately sized (8x10 and not 20 x 26)


Deficiencies and TV's provided per Title 22. Exit interview completed with Licensee, Jasmin and House Manager, Myra. A copy of this report, deficiencies, TV's and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 12/05/2024 05:20 PM - It Cannot Be Edited


Created By: Mary Garza On 12/05/2024 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: AT HAVEN HOME II
FACILITY NUMBER: 247209199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (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.
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Licensee stated they will make repairs to the items listed. Licensee stated they will provide pictures to CCL by POC date as proof of correction.
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This requirement was not met as evidence by LPA observation of Room 10 observed with hole behind door in need of repair. Clutter in garage in need of removal. Refrigerator in garage in need of cleaning/repair. Hood vent observed open and in need of repair under kitchen cupboard. Bottom kitchen cupboard door broken and in need of repair/replacement.
Front door observed broken and not properly latching. This poses a potential health safety and or personal rights risk to residents in care.
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Type B
12/20/2024
Section Cited
CCR87468.1(a)(6)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.
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Licensee will have a meeting with family and staff regarding regulation. In-service sign in sheet and training material will be sent to CCL by POC date. Chair and locks will be removed. Pictures will be provided to CCL as proof of correction by POC date.
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This requirement was not met as evidence by LPA observation of R1's window observed locked with board preventing from opening R1's exit door observed blocked with chair preventing from exiting. Front door observed with lock at bottom of door.
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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:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/05/2024 05:20 PM - It Cannot Be Edited


Created By: Mary Garza On 12/05/2024 at 04:26 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: AT HAVEN HOME II
FACILITY NUMBER: 247209199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care...(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Licensee stated they will provide a plan of correction in writing by POC date. In-service training will be completed with all staff. In- service sign in sheet and training material will be submitted as proof of correction within 7 days to CCL..
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This requirement was not met as evidence by: LPA observation of medications observed unlocked/accessible in kitchen cupboard, kitchen refrigerator, in R6 closet and hallway cupboard. This poses an immediate health, safety and 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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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