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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206812
Report Date: 12/12/2022
Date Signed: 02/23/2023 06:20:21 AM


Document Has Been Signed on 02/23/2023 06:20 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:CLEAR VIEW RETIREMENT GROUP/JONFACILITY NUMBER:
107206812
ADMINISTRATOR:LASHAY C DUSTINFACILITY TYPE:
740
ADDRESS:2846 E. JON DRIVETELEPHONE:
(559) 322-7368
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
12/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Shay DustinTIME COMPLETED:
03:00 PM
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On 12/12/22, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit. LPA introduced self and was allowed entrance by staff. LPA V Gorban met with Administrator, Shay Dustin and stated reason for visit.

LPA arrived at the facility to conduct case management visit to relay information about Immediate Exclusion order for Staff Member #1. LPA verified with administrator that S1 has not worked in facility since some time. Administrator responded that S1 has not been with the facility for almost two years, Administrator was advised an exclusion has been ordered and issued by the Department and provided an exclusion order document for the facility stated above. Per administrator S1 was disassociated from facility personnel and report provided by LPA.

No deficiencies sited during this Case Management visit. An exit interview was conducted and report signed on-site and a copy of report will be provided for the facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
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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