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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203506
Report Date: 02/26/2024
Date Signed: 02/26/2024 01:37:03 PM

Document Has Been Signed on 02/26/2024 01:37 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:SVS CLOVIS ADULT DAY PROGRAMFACILITY NUMBER:
107203506
ADMINISTRATOR:BANUELOS, CHERIFACILITY TYPE:
775
ADDRESS:155 PARK CREEK DRIVE, #101TELEPHONE:
(559) 323-0537
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 90CENSUS: 77DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Alexandra WilliamsTIME COMPLETED:
01:45 PM
NARRATIVE
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On 02/26/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual
inspection. LPA introduced self, stated the purpose of the visit and meet with Administrator Alexandra Williams. LPA conduct tour with Administrator. 37 clients were present during the inspection.

Facility is maintained at a comfortable temperature and no passageway obstructions or fire hazards were observed inside. LPA toured program classrooms: library, quiet room, arts and craft, music, movie, computer lab, gym, kitchen, game, and drama room. Client locked lockers were observed in the drama and movie room. LPA observed locked medications in the Administrator office. MARs were reviewed. Transportation is available and provided for clients. Kitchen was toured. Clients bring their own lunch to program. Water fountain observed operational. Client restrooms were toured, observed to be clean, and operational. Fire extinguishers throughout the facility was observed with served date: 12/18/23. Chemicals and cleaning supplies were observed locked in the 2nd supply closet. A sample of client and staff files were reviewed to have the required documents. LPA observed S1 with clients in activity room. LPA verified S1 fingerprint is not cleared and not associated with facility.

A deficiency is being cited on the attached Lic 809D and an immediate Civil Penalty of $500 was assessed.
See Lic 421BG is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title
22, Division 6.

Exit Interview conducted. The following documents are requested and to be submitted to Fresno CCL by: 03/04/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610D, Lic 9020, and Lic 9283. A copy of this report and appeal rights was provided to the Administrator, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2024
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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Document Has Been Signed on 02/26/2024 01:37 PM - It Cannot Be Edited


Created By: Mai Yang On 02/26/2024 at 01:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SVS CLOVIS ADULT DAY PROGRAM
FACILITY NUMBER: 107203506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
1522(c)(1) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA review records reviewed of the department’s Facility Personnel Report Summary, S1 not fingerprinted cleared and not associated with facility while providing supervision to clients which poses an immediate risk to the health and safety of the clients.
POC Due Date: 02/27/2024
Plan of Correction
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Staff person is to be removed from the facility and not permitted back until fingerprinted cleared and associated with facility. POC cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024


LIC809 (FAS) - (06/04)
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