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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202451
Report Date: 02/13/2024
Date Signed: 02/14/2024 02:16:24 PM


Document Has Been Signed on 02/14/2024 02:16 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:GOLDEN YEARS III RCHE, THEFACILITY NUMBER:
107202451
ADMINISTRATOR:GALVEZ, MARLENEFACILITY TYPE:
740
ADDRESS:7641 N. MANSIONETTE DRTELEPHONE:
(559) 271-2823
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Carlo SantosTIME COMPLETED:
04:35 PM
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On 02/13/2024, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured facility with facility staff, Michael Bacani. Administrator (AD) Carlo Santo was notified of Licensing visit over the phone and arrived shortly to attend the visit.
Facility has one entrance/exit point. LPA with staff toured facility inside and out.

The facility was observed to be at a comfortable temperature, of 74 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed some residents in common area after lunch watching television, others in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility.

Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

Fire extinguisher was observed with a service date of 03/29/2023. All residents’ bedrooms were observed to be with comfortable temperature. Bathrooms water temperature was tested and recorded reading of 115 degrees F.
Medications observed to be locked in a cabinet in the common area. LPA reviewed medication records appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the storage it the laundry room. An outdoor seating area was observed operational for residents in care.

LPA reviewed staff and residents’ files. No deficiencies were observed and cited.
Exit interview conducted. A report was signed and copy of this report was provided for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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