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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206911
Report Date: 08/14/2023
Date Signed: 08/14/2023 11:11:11 AM

Document Has Been Signed on 08/14/2023 11:11 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:CAROLINA HOMEFACILITY NUMBER:
107206911
ADMINISTRATOR:MISTY BRYSONFACILITY TYPE:
735
ADDRESS:1086 CAROLINA AVENUETELEPHONE:
(559) 326-7758
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 4CENSUS: 4DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Jesus Garcia Munoz, Program Director TIME COMPLETED:
11:20 AM
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On 08/14/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. Upon arrive LPA knocked on the door no client and staff present. LPA called Area Director (AD) Katherine Chattom stated the purpose of the visit. AD stated AD and Administrator Misty Bryson is not able to attend meeting. AD stated Jesus Garcia Munoz, Program Director (PD) will attend meeting and authorized to sign and receive report. PD arrived shortly and Program Supervisor (PS) Brandy Woodworth. LPA toured facility with PD and PS. No clients were present upon LPA arrival. One client arrived later during inspection.

The tour started in the kitchen into the common areas, to the client's bedrooms, and bathrooms. 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. An adequate supply of perishable and


non-perishable food was observed. Temperature maintained for refrigerator at 39 degrees F and freezer at 0 degrees F. Cleaning supplies and chemicals stored and locked under kitchen sink. Fire extinguisher was observed with a service date of: 04/11/23. Fire drill last completed:07/04/23.

Medications observed kept locked in medication cart. MARs were reviewed. All 4 single occupant bedrooms were observed to have required furnishings and with adequate lightening. Bathrooms were properly equipped, and the hot water temperature was tested at 106.4 in bathroom 1 and degrees F 106.8 degrees F in bathroom 2. Fire extinguisher was observed with a service date of: 04/11/23. Fire drill last
completed:07/04/23. Outside of facility toured and observed to be free of debris. Side gate observed self-closing. Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ file reviewed to have update emergency contacts, Admission agreement, and Pre-Appraisal.

LPA will return to review staff records and complete annual inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 08/21/23.
Forms requested: Lic 308, Lic 500, Lic 610D, Lic 9282, current Administrator Certificate. A copy of
this report was provided to Administrator, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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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