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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100406786
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:25:25 PM

Document Has Been Signed on 10/21/2022 04:25 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:ESPERANCE CENTER, NORTHFACILITY NUMBER:
100406786
ADMINISTRATOR:TYREE, DEANNAFACILITY TYPE:
735
ADDRESS:10496 N. ARMSTRONGTELEPHONE:
(559) 297-0826
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 5DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Direct Support Professional, Rebecca BriamTIME COMPLETED:
03:45 PM
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On 10/21/2022, Licensing Program Analysts (LPAs) V. Gorban and S Hurt arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced selves, stated the purpose of the visit, and was granted entry to the facility by DSP Rebecca Briam.

Visitor log-in/temperature check station was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff was observed with mask covering.

The facility was observed to be at a comfortable temperature, free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. Chemicals, and cleaning supplies were locked in a closet, Residents and stuff files were reviewed and locked in a closet in administrator's room. PPE were observed in sufficient amount of 30- day supply. A 2-day supply of perishable and 7-day supply of non-perishable food was observed to be properly stored and labelled. Resident's all five bedrooms were to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms have adequate lighting, hot water temperature to be in proper range of 115 degree Fahrenheit. Showers have non slip floor mats and trash cans have lids.

No deficiencies were observed and cited on todays visit. Exit interview conducted and copy of this report printed and left at facility.
Continue LIC809 on following page.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ESPERANCE CENTER, NORTH
FACILITY NUMBER: 100406786
VISIT DATE: 10/21/2022
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Residential Facility (ARF):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Administrator Certificate.


Please submit the above forms/information to Fresno CCL by: 11/05/2022

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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