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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708852
Report Date: 07/10/2024
Date Signed: 07/23/2024 09:55:38 PM

Document Has Been Signed on 07/23/2024 09:55 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:MAGALLANES REST HOMEFACILITY NUMBER:
270708852
ADMINISTRATOR/
DIRECTOR:		MAGALLANES, LYDIAFACILITY TYPE:
740
ADDRESS:193 LILLIAN PLACETELEPHONE:
(831) 917-3584
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 6CENSUS: 1DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:49 AM
MET WITH:Licensee Lydia MagallanesTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 7/10/24, Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a required Annual Inspection visit. LPA introduced herself, stated purpose of visit, and was allowed entrance by Licensee Lydia Magallanes.

LPA toured the inside of the facility including entry, kitchen, dining, living room, bedrooms, & bathrooms. All fire exit routes were free and clear of obstruction. LPA observed medications are stored in a locked cabinet. LPA observed Centrally Stored Medication Log to not be completed properly. Knives and sharp objects are secured. LPA observed cleaning supplies accessible to resident in the bathroom under the sink and in the shower. Licensee did not have current liability insurance for the facility. Licensee did not have current disaster plan.

Facility has 3 bedrooms and 2 bathrooms. Resident has their own bedroom. There is currently only one resident living at the facility.

Licensee has one new fire extinguisher and is in good standing. Smoke alarms are in working condition. Carbon monoxide detector was tested and in working condition. Water temperature was checked in the resident's bathroom. .

Citations issued per the California Code of Regulations Title 22.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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 3
Document Has Been Signed on 07/23/2024 09:55 PM - It Cannot Be Edited


Created By: Brianna Miranda On 07/10/2024 at 03:37 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: MAGALLANES REST HOME
FACILITY NUMBER: 270708852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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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4
Based on observation, the licensee did not comply with the section cited above by leaving cleaning supplies accessible to resident in care, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed cleaning supplies under the bathroom sink and in the shower.
POC Due Date: 07/11/2024
Plan of Correction
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Licensee will remove the items and place in a locked secured area. Verification will be sent to LPA
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above due to medication of resident not being properly logged on the Centrally Stored Log, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Licensee will use the Centrally Stored Log LPA provided and send verification to LPA.
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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/23/2024 09:55 PM - It Cannot Be Edited


Created By: Brianna Miranda On 07/10/2024 at 03:37 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: MAGALLANES REST HOME
FACILITY NUMBER: 270708852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, & record review, the licensee did not comply with the section cited above by not having current insurance liability, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Policy will be purchased and verification will be sent to LPA.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above the licensee does not have a current disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee will create a disaster plan and provide verification to LPA.
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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
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