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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208807
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:21:19 AM


Document Has Been Signed on 08/29/2024 11:21 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:MRS SCOTT'S WHERE THE HEART IS HOMES-SAN FRANCISCOFACILITY NUMBER:
107208807
ADMINISTRATOR:BRICE, NASTASSHAFACILITY TYPE:
740
ADDRESS:149 OAK AVENUETELEPHONE:
(559) 765-4287
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
08/29/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator MaDivina “Grace” Petil TIME COMPLETED:
11:25 AM
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On this day Licensing Program Analysts (LPA) M. Yang and R. Bruce arrived unannounced to conduct a POC visit. LPAs met with Staff Enrico Mangunay Yabut. Administrator MaDivina “Grace” Petil was called and arrived shortly.

LPAs received copy of S1 First Aid/ CPR certification with completion date of 08/26/24.

LPAs was informed Administrator schedule appointment for R1 and R2 for TB testing to be completed on 08/29/24. TB result for R1 and R2 shall be submitted to the department by 9/16/24.

LPAs observed the following:
1. Non-skid mat in the bathroom tub and shower.
2. Fire extinguisher delivered to the facility on 08/28/24.

An exit interview was conducted. A copy of this report was provided to Administrator, whose signature confirm receipt of report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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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