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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206629
Report Date: 06/05/2023
Date Signed: 07/13/2023 05:17:49 PM

Document Has Been Signed on 07/13/2023 05:17 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:ELIM PLACEFACILITY NUMBER:
107206629
ADMINISTRATOR:WOLF, RACHEL E.FACILITY TYPE:
740
ADDRESS:1808 5TH STREETTELEPHONE:
(559) 875-7268
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY: 44CENSUS: DATE:
06/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Administrator, Maria CeballosTIME COMPLETED:
06:24 PM
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On 6/5/23 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Administrator, Maria Ceballos. LPA introduced self, explained reason for visit and was permitted entry into the facility.

LPA completed a health and safety check on residents in care. LPA toured the facility. Residents observed in common areas and in rooms. 1 of 6 residents rooms (Rm# 12A) observed with an oxygen tank. Room observed without required oxygen posting. Pathways and doors were clear and free from obstruction. Facility was without odor. LPA observed 1 of 4 restrooms to contain several black garbage bags of dirty clothing. Common areas adequately furnished, and adequately lit. Fire extinguisher last serviced 9/2/22. Resident rooms observed to have the required furnishings and with adequate lighting. Chemicals and medications were located in locked rooms. LPA observed sufficient seating under covered patio area.

LPA requested the following documents to be submitted to CCL by 6/16/23: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with Licensee, Rachel Wolf and Administrator, Maria Ceballos. A copy of this report given via email at racheal@elimcare.com and Maria@elimcare.com for signature. A delivered and read receipt serves as confirmation.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023
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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