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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204055
Report Date: 11/29/2023
Date Signed: 11/30/2023 08:43:39 AM

Document Has Been Signed on 11/30/2023 08:43 AM - 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:SENGSIRI HOMEFACILITY NUMBER:
107204055
ADMINISTRATOR:SENGSIRI, BRIGIDAFACILITY TYPE:
735
ADDRESS:1142 CARSON AVENUETELEPHONE:
(559) 325-1752
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Bridgida Sengsiri, LicenseeTIME COMPLETED:
07:00 PM
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On 11/29/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met with Licensee (L1) Bridgida Sengsiri. LPA toured facility with L1. All six clients were present during inspection.

The facility was observed to be at a comfortable temperature of 73 degrees F, clean, in good repair, and no
passageway obstructions or fire hazards were observed inside or outside. Knives were observed locked and accessible to clients under kitchen shelf. An adequate supply of perishable and non-perishable food was observed. Fire extinguisher was observed with a service date of: 11/03/23. Last fire drill completed on 10/13/23. Medications observed kept locked in kitchen shelf. MARs were reviewed. LPA observed extra linens.

All bedrooms were observed to have the required furnishings and with adequate lightening. The bathroom was properly equipped and operating.Hot water temperature was tested. Cleaning supplies and chemicals stored and locked in laundry shelf. Outside of facility toured and observed to be free of debris. Side gate observed self-closing and self-latching.

LPA reviewed four client files to have all the required documents. All staffs’ files were also reviewed. All staff files were observed to have current First Aid/CPR, fingerprinted clear and associated to the facility. Carbon monoxide and smoke detectors were tested and observed to be operational.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 12/05/23.
Forms requested: Lic 308, Lic 500, Lic 610D, and current Administrator certificate. A copy of this report was provided to Licensee whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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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