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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200922
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:57:24 PM

Document Has Been Signed on 09/08/2023 12:57 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:LOOP #3FACILITY NUMBER:
107200922
ADMINISTRATOR:LOOP, STEVEFACILITY TYPE:
735
ADDRESS:7931 NORTH BAIRD AVENUETELEPHONE:
(559) 299-9413
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 4CENSUS: 4DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
11:30 AM
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On 9/08/2023 Licensing Program Analyst (LPA) V Gorban arrived unannounced for an Annual Required Inspection. LPA met at the door with staff Joseph Rafanan. LPA stated the purpose of the visit and was allowed entry. Administrator (AD) Steve Loop was notified of Licensing visit, administration certification number 6033165735 expiration date 08/23/23, AD is expecting to receive updated licence soon.

During this visit LPA toured facility with staff inside and out. Facility has one entrance/exit point. At the time of the visit there were only two clients present.
Facility appeared clean, comfortable temperature recorded at 73 Degrees Fahrenheit with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Bathrooms have trash cans with lid. The exterior tour was conducted. Facility as three bedroom house, two private rooms and one shared. Two independent clients have its own bedroom. Every room is fully furnished. LPA reviewed clients file for emergency contact and physician report.

Kitchen observed with free of clutter and obstruction. Sharp items placed away and locked. Kitchen refrigerator was checked. LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored.

Cleaning supplies were observed to be locked in a laundry room. Records were reviewed for infection control training. Fire extinguisher in compliance, service date 12/30/2022.

Medications were observed to be locked in common room. Facility uses to document file for administration for dispense, document, track clients’ medications. First aid kit was observed and contained all required items.
Carbon monoxide and smoke detectors were tested and observed to be operational.

Report continues on LIC809-C
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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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: LOOP #3
FACILITY NUMBER: 107200922
VISIT DATE: 09/08/2023
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Exit interview was conducted. No citations were issued on this visit. Copy of this report printed and provided to for facility records.

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 Day Program (ADP):


· 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


LPA observed and confirmed presence of required documents at the facility.

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: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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