107201156-3-28-2023-24-AS-BMIA-CQCKWE-20230328081546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201156
Report Date: 03/24/2023
Date Signed: 03/28/2023 08:15:53 AM

Document Has Been Signed on 03/28/2023 08:15 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:	FAIRWINDS - WOODWARD PARK		FACILITY NUMBER:	107201156
ADMINISTRATOR:	VALERO, DESIREE		FACILITY TYPE:	740
ADDRESS:	9525 N FT WASHINGTON RD		TELEPHONE:	(559) 434-6444
CITY:	FRESNO	STATE: CA	ZIP CODE:	93730
CAPACITY:	270	CENSUS: 218	DATE:	03/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Administrator- Desiree Valero		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/24/2023 at 11:20 a.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility to conducted an unannounced Annual Required Inspection. LPA toured the facility with Administrator/General Manager Desiree Valero. LPA explained the reason for the visit and a tour was conducted. LPA toured the facility inside and out. LPA observed exits to be clear and free from obstructions. LPA observed fire extinguishers to be current and in good standing. Water temperature was taken in 2 common area bathrooms and one vacant room. The common areas, beauty shop, activities room and dining room were all toured. LPA observed adequate seating and lighting for resident throughout facility. LPA observed residents participating in different activities throughout facility tour. The kitchen was toured. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. All food was labeled and properly stored. LPA observed kitchen staff wearing gloves and masks. LPA observed facility to be clean and free from clutter. LPA also observed various residents interacting with one another and with staff. Resident files reviewed. Staff files reviewed. Medications observed to be locked in medication room and inaccessible to residents. Exit interview was conducted and a copy of this report & LIC809C was provided to AD.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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: FAIRWINDS - WOODWARD PARK	FACILITY NUMBER: 107201156
	VISIT DATE: 03/24/2023

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RCFE Docs

Residential Care Facility for the Elderly (RCFE):
 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 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
 LIC 9020 Register of Facility Clients/Residents
 Copy of current Liability Insurance
 Copy of current Administrator Certificate
 Alternate contact information including name, telephone number, & email address.

Requested information will be due by 4/7/2023

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC809 (FAS) - (06/04)

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