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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400448
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:03:09 PM


Document Has Been Signed on 12/27/2023 03:03 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:NAZARETH HOUSEFACILITY NUMBER:
100400448
ADMINISTRATOR:O'NEILL, ROSEMARY, R.N.FACILITY TYPE:
740
ADDRESS:2121 NORTH FIRST STREETTELEPHONE:
(559) 237-2257
CITY:FRESNOSTATE: CAZIP CODE:
93703
CAPACITY:110CENSUS: 72DATE:
12/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Rosemary O’NeillTIME COMPLETED:
03:15 PM
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On 12/27/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct a case management regarding a complaint the department received regarding multiple falls Resident (R1) had that were not reported to Licensing.

LPA met with Administrator Rosemary O’Neill and informed the reason for visit. LPA completed facility file review and observed very few incident reports from October 2023 to December 2023. LPA reviewed incident report submitted to Licensing on 9/15/2023 for R1 regarding a fall and death report from 9/17/2023.

No deficiencies observed.

An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy
provided with appeal rights.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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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