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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203196
Report Date: 04/25/2023
Date Signed: 04/26/2023 02:10:03 PM


Document Has Been Signed on 04/26/2023 02:10 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:CARING HEART-EVERGLADEFACILITY NUMBER:
107203196
ADMINISTRATOR:RAMIREZ, CLEOFACILITY TYPE:
740
ADDRESS:2862 EVERGLADETELEPHONE:
(559) 325-5797
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 6DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Administrator, Cleo RamirezTIME COMPLETED:
12:00 PM
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On 4/25/2023, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct a required annual inspection. LPA met with administrator Cleo Ramirez and announced the purpose of the visit.

LPA toured the facility inside and outside. The facility was at a comfortable temperature and adequately furnished. All passageways and exits were clear and free from obstruction. Facility had carbon monoxide and smoke detectors which were functioning. Facility fire extinguisher was serviced on 2/24/23 and also facility is equipped with emergency pull box. The facility phone was checked, operational and functioning. LPA toured resident bedrooms and bathrooms. All six bedrooms were adequately furnished and lit. Bathrooms were clean, odor free, and all fixtures were functioning properly.
LPA observed two-day supply of perishable food stuffs and seven-day supply of non-perishable food stuffs. Medications were locked in a cabinet in the kitchen and appear to be administered properly.
LPA reviewed Staff and Resident files. LPA reviewed emergency preparedness plan.

No deficiencies were cited during the inspection. Exit interview conducted. A copy of the report was provided.


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.

Continue on LIC809 C.....

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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: CARING HEART-EVERGLADE
FACILITY NUMBER: 107203196
VISIT DATE: 04/25/2023
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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
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: 04/30/2023

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: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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