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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208825
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:00:22 PM


Document Has Been Signed on 12/06/2022 12:00 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:FAMILY IS WHYFACILITY NUMBER:
107208825
ADMINISTRATOR:DEANGELA TEASLEYFACILITY TYPE:
740
ADDRESS:2495 S. RABETELEPHONE:
(334) 652-9491
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 4DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Administrator DeAngela TeasleyTIME COMPLETED:
12:30 PM
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On 12/06/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Caregiver Shannikia Wilks. Facility tour was conducted with Administrator DeAngela Teasley

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Hand washing and other various Covid-19 related signs were observed in the common areas.

All pathways, entrances and exits were clear from obstructions. No fire clearance issues. Facility staff observed with facial coverings. LPA toured the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Sharps were kept in locked container in kitchen cabinet. LPA observed a 30-day supply of PPE and cleaning supplies. Facility has 2 private bedrooms and 1 shared bedroom. Beds in the shared bedroom were 3 feet apart. LPA checked residents' medication and observed a 30-day supply. Resident’s files have updated emergency contact information. Staff files were reviewed for good health. No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/13/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site by Administrator; a copy of this report will be provided via email.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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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