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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202348
Report Date: 03/13/2024
Date Signed: 03/15/2024 09:55:04 AM

Document Has Been Signed on 03/15/2024 09:55 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:CLEARVIEW CAREHOMES,INC.FACILITY NUMBER:
355202348
ADMINISTRATOR:FELICIDAD RAMOS KANKELBORGFACILITY TYPE:
740
ADDRESS:3370 CIENEGA ROADTELEPHONE:
(831) 637-4463
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 6CENSUS: 4DATE:
03/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Felicidad Ramos Kankelborg - AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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On 3/13/2024, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with administrator Felicidad Ramos Kankelborg and announced the purpose of the inspection.

During the inspection, LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. Fires extinguishers were accessible and recently serviced. Smoke and carbon monoxide detectors were present and functioning properly. LPA observed a sufficient supply of foodstuffs which were properly stored and labeled. The outdoor areas were free from hazard and provided adequate seating for all residents in a covered area. Resident medications were centrally stored in a locked cabinet, and medications appeared to be administered properly.

Common areas were clean, odor free, and adequately lit. Resident bedrooms and bathrooms were clean, odor free, and provided the minimum required furnishings. Bathrooms were clean and odor free. Non-skid mats and secure grab bars were observed in showers, and all fixtures were functioning properly. Hot water was within required temperature range.

At 2:10 pm, during record review, facility staff were unable to produce a completed emergency disaster plan. See attached LIC809D for deficiency cited in accordance with Health and Safety Code, Section 1569.695(a). Facility Administrator agreed to complete an Emergency Disaster Plan LIC610E for review by the department. Appeal rights were provided to the Administrator.

Exit interview was conducted and a copy of the report was provided via email.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
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 03/15/2024 09:55 AM - It Cannot Be Edited


Created By: David Ayers On 03/13/2024 at 02:45 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
,
, CA

FACILITY NAME: CLEARVIEW CAREHOMES,INC.
FACILITY NUMBER: 355202348

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above and was unable to provide one out of one emergency disaster plan for review, which posed a potential health, safety and personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Administrator had agreed to complete an emergency disaster plan (LIC610E) and provide it to CCLD for review by POC due date. LIC610E will be posted in the facility and facility staff will be briefed on emergency disaster procedures.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Ayers
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024


LIC809 (FAS) - (06/04)
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