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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208847
Report Date: 11/22/2022
Date Signed: 11/22/2022 03:58:50 PM

Document Has Been Signed on 11/22/2022 03:58 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:JAMES LINWOOD RCHFACILITY NUMBER:
547208847
ADMINISTRATOR:VILLELA, LETICIAFACILITY TYPE:
740
ADDRESS:111 1/2 S LINWOOD STTELEPHONE:
(559) 732-8992
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 6CENSUS: 6DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Leticia Villela, Licensee/AdministratorTIME COMPLETED:
04:20 PM
NARRATIVE
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On 11/22/22 at 2:09 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. LPA met with Licensee/Administrator (LIC) Leticia Villela.

LPA toured inside and outside of the facility. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed next to the sinks. Bedrooms were checked. LPA checked residents’ medications and observed the month's supply. Cleaning and PPE supplies were checked. There were no fire clearance issues. Administrator certification is valid.

The following deficiencies were observed:
1. Kitchen knives and scissors observed stored in cabinet under sink where cleaning and chemicals are stored.
2. S1 did not have a completed health screening and has been working since 5/5/22.

The following updated forms to be sent to CCL within 2 weeks:
LIC500, LIC610E, LIC400, LIC402

Deficiencies are being cited based on LPAs' observations, interview, and records review in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted and a Plan of Correction was reviewed and developed with Licensee. A copy of this report and appeal rights were given to Licensee Leticia Villela, whose signature confirms receipt of this report.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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 11/22/2022 03:58 PM - It Cannot Be Edited


Created By: Malia Thao On 11/22/2022 at 03:31 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: JAMES LINWOOD RCH
FACILITY NUMBER: 547208847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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. S1 did not have a completed health screening and has been working since 5/5/22, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2022
Plan of Correction
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Licensee will submit proof of completed health screening for S1 to CCL by POC due date.

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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2022 03:58 PM - It Cannot Be Edited


Created By: Malia Thao On 11/22/2022 at 03:33 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: JAMES LINWOOD RCH
FACILITY NUMBER: 547208847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(24)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2022
Plan of Correction
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Licensee immediately removed knives from cabinet and placed in locked staff area pending POC. Licensee will submit proof of newly installed lock for kitchen cabinet to store knives to CCL by POC due date.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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