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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202381
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:52:34 PM


Document Has Been Signed on 09/04/2024 03:52 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:GIFT OF GRACE CARE HOMEFACILITY NUMBER:
107202381
ADMINISTRATOR:PAMELA LEWISFACILITY TYPE:
740
ADDRESS:1480 W. SAN MADELE AVENUETELEPHONE:
(559) 284-8857
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Phoeun MarezTIME COMPLETED:
11:01 AM
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On 9/4/24 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met by Care Giver, Josephine Jo and Care Giver, Ryan Figueroe. LPA introduced self, explained reason for visit and was permitted entry into the facility. Administrator, Phoeun Marez was contacted and arrived some time later.

A health and safety check was completed for residents in care. Residents observed in common area.

Case management visit was conducted to follow up on proof of corrections on deficiencies previously cited. Water temperature was measured at 109 degrees F within regulation. POC cleared.

During tour of facility LPA observed chemicals in restroom #1 and medications in refrigerator lock box unlocked and accessible to residents in care. POC not cleared.

Exit interview completed with Administrator, Phoeun Marez. A copy of this report and POC clearance letter provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
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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