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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202828
Report Date: 11/03/2022
Date Signed: 11/07/2022 02:35:37 PM


Document Has Been Signed on 11/07/2022 02:35 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:A PLACE CALLED HOME RESIDENTIAL CARE 5FACILITY NUMBER:
107202828
ADMINISTRATOR:MURCHISON, COLINFACILITY TYPE:
740
ADDRESS:10736 E MENDOCINO BAYTELEPHONE:
(559) 213-7251
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 6DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Admininstrator, Colin MurchisonTIME COMPLETED:
01:00 PM
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On 11/03/22, Licensing Program Analyst (LPA) V Gorban unannounced Annual Required Infection Control Inspection. LPA observed a central entry point with a supply of hand sanitizer located upon entry. A sign in policy that includes documented routine symptom screening for visitors is currently being implemented to follow current visitation guidelines. LPA introduced self and stated purpose of visit , LPA met with Colin Murchison, Administrator Certificate #6035094740, expires 05/06/23.

Facility toured with Administrator. All six bedrooms are single occupancy, fully furnished, some bedrooms share walk in shower and bathroom., others have its own. Residents present during today's inspection observed to be sitting in dining/activity areas for breakfast watching a television and others resting in their bedroom. Kitchen toured, LPA observed facility to have a 2-day of perishable and a 7-day supply of non-perishable food available. Medications are locked and secured in medication room, residents observed to have a 30-day supply of medication available. PPE is locked and secured and available if necessary.

Carbon Monoxide detectors are linked with fire alarm and observed to be operational during today's inspection. Fire extinguishers present with a service date of 02/08/22.

No deficiencies observed.

Exit interview conducted. Report signed on site and a copy provided to Administrator for facility records
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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: A PLACE CALLED HOME RESIDENTIAL CARE 5
FACILITY NUMBER: 107202828
VISIT DATE: 11/03/2022
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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:

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.

Please submit the above forms/information to Fresno CCL by: 11/25/2022

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.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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