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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206911
Report Date: 08/15/2023
Date Signed: 08/15/2023 02:29:31 PM

Document Has Been Signed on 08/15/2023 02:29 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:CAROLINA HOMEFACILITY NUMBER:
107206911
ADMINISTRATOR:MISTY BRYSONFACILITY TYPE:
735
ADDRESS:1086 CAROLINA AVENUETELEPHONE:
(559) 326-7758
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 4CENSUS: 4DATE:
08/15/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Administrator Misty Bryson TIME COMPLETED:
02:45 PM
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On 08/15/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct a continuation of the Required Annual Inspection. LPA met with Administrator Misty Bryson and stated the purpose of the visit.

Staff files were reviewed. Staff files were observed to have current First Aid/CPR, Personnel Record, and TB results. Staff are fingerprinted clear and associated to the facility.



No deficiencies issued during this inspection.

An exit interview was conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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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