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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206816
Report Date: 11/09/2022
Date Signed: 11/09/2022 04:31:45 PM


Document Has Been Signed on 11/09/2022 04:31 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:CLEAR VIEW RETIREMENT GROUPFACILITY NUMBER:
107206816
ADMINISTRATOR:LASHAY C DUSTINFACILITY TYPE:
740
ADDRESS:2380 E. EL PASOTELEPHONE:
(559) 298-2877
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 5DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:House Manager, Clinton Arciete TIME COMPLETED:
03:30 PM
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On 11/09/2022 licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced. Upon arrival, LPA met with House manager Clinton Arciete, and addressed the purpose of today's visit. House Manager conducted the infection control/prevention screening, took LPA's body temperature, then checked LPA in the visitor log book. Administrator was not available at the time but was notified of LPA’s visit. Administrator certificate expiration date is 12/09/2022.

LPA observed the COVID-19 posters in facility. Hand sanitizers were observed at many places in facility. LPA toured the facility inside out with House manager. LPA inspected, bedrooms, living room, dining room, and medication storage. There are 5 resident shared private individual rooms of four females and one male. There are three common restrooms for residents to share in facility.

LPA inspected the kitchen and checked the food supplies. Two days perishable foods and seven days non perishable foods were observed sufficient. LPA inspected the PPE supplies. PPE supplies were observed sufficient. All the staff were observed wearing mask. The trash cans in facility are with covers. LPA inspected the backyard of the facility. The ground surface is even. There is no obstruction in backyard. Facility supplied with emergency pull fire alarm, Fire extinguisher serviced on 02/13/22

LPA reminded House manager of upcoming annual fees due date.

No citation was issued for today's inspection. Exit interview was conducted with House Manager. This report signed and copy provided to facility.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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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: CLEAR VIEW RETIREMENT GROUP
FACILITY NUMBER: 107206816
VISIT DATE: 11/09/2022
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Residential Care Facility for the Elderly (RCFE):
· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· 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: 11/25/2022

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: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2