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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100408901
Report Date: 12/13/2022
Date Signed: 12/13/2022 11:42:28 AM


Document Has Been Signed on 12/13/2022 11:42 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:GARDEN MANORFACILITY NUMBER:
100408901
ADMINISTRATOR:BLACK, JOANFACILITY TYPE:
740
ADDRESS:4983 E. OLIVETELEPHONE:
(559) 255-8650
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:49CENSUS: 42DATE:
12/13/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Office Manager Joanna TilghmanTIME COMPLETED:
11:40 AM
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On 12/13/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection -Infection Control. LPA met with Office Manager Joanna Tilghman and stated the purpose of the visit.

Visitor log-in/temperature check, masks, and disinfection station were not observed upon entry. Facility has one entrance/exit point. Facility staff observed without facial coverings. Facility appeared clean with no obstruction or fire clearance issues. Facility did not have Covid-19 related signs in the common areas.

Sharp items are kept locked in the kitchen. cleaning supplies were secured in a locked in garage. Medications were secured and locked in the medication room. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the Living room was last serviced on 6/1/2022 and was fully charged. Cleaning and PPE supplies were locked in the garage. Bathrooms have trash cans without lids. Some hand washing posters were observed in the bathrooms by the sink. Staff records were reviewed for good health and CPR/First Aid training. Resident’s files have updated emergency contact information.

No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/23/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster (LIC610E)

An exit interview was conducted with Office Manager. Report signed on-site and printed copy provided.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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