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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206901
Report Date: 01/24/2024
Date Signed: 01/24/2024 04:50:43 PM


Document Has Been Signed on 01/24/2024 04:50 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:A PLACE CALLED HOME RESIDENTIAL CARE 4FACILITY NUMBER:
107206901
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2842 CALIMYRNA AVETELEPHONE:
(559) 326-0953
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee David MurchisonTIME COMPLETED:
02:30 PM
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On 1/24/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met caregiver April Rose Salise. LPA toured facility with caregiver. Licensee David Murchison was called and arrived shortly during tour. All four residents were present during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Medications were observed locked in kitchen shelves and drawers. MARs were reviewed. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 40 degrees F and freezer at 0 degrees F. Fire extinguisher was observed with a service date of: 2/9/24. Cleaning supplies and chemicals stored and locked in garage and laundry room. Extra linens were observed. Washer and dryer observed operational during inspection. All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested at 109.5 degree F in the bathroom 1, 109.9 degree F in bathroom 2, and 108.5 degree F in bathroom 3. Outside of facility toured and observed to be free of debris. Side gate observed self-closing and self-latching. Adequate outdoor seatings available for residents. All residents’ and staff files were reviewed to have all the required documents.

No deficiency cited during inspection.

Exit Interview conducted. A copy of this report was provided to Licensee, whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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