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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200910
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:45:07 PM

Document Has Been Signed on 07/25/2024 01:45 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:EDDIE'S TERRACE #3FACILITY NUMBER:
107200910
ADMINISTRATOR/
DIRECTOR:		HENDRICKS, STEPHANIEFACILITY TYPE:
735
ADDRESS:3450 W. SIERRATELEPHONE:
(559) 431-6859
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 4DATE:
07/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Administrator Rachel Derby TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 07/25/24, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management visit to the facility. The purpose of the case management visit is to follow up on Special Incident Reports (SIR) submitted to CCL Office. LPA met Administrator Rachel Derby.

Facility reported on 07/13/24, C1 went AWOL and police was called. Administrator stated C1 returned back to the facility on 07/18/24.

The information provide will be reviewed; a follow up case management will be conducted if necessary.

Exit interview was conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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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