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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208837
Report Date: 11/06/2023
Date Signed: 11/06/2023 02:22:57 PM


Document Has Been Signed on 11/06/2023 02:22 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:CATUIRA HOME IIFACILITY NUMBER:
107208837
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:2478 HANSON AVENUETELEPHONE:
(559) 515-6071
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Camalah Kopacz TIME COMPLETED:
02:45 PM
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On 11/06/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met caregiver Annmarie Bushay. LPA toured facility with caregiver. Administrator Camalah Kopacz was called and arrived shortly during tour. One resident was 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. An adequate supply of perishable and non-perishable food was observed. Fire extinguisher was observed with a service date of: 06/2/23. Fire drill last completed:08/12/23. Medications observed locked in kitchen shelf. MARs were reviewed.

All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured. Bathrooms were observed operational during inspection. Hot water temperature was tested range between 106.4 and 107.1 degree F in the master bathroom and 114.3 degree F in bathroom 1. Cleaning supplies and chemicals stored and locked under kitchen sink and in laundry shelves. Outside of facility toured and observed to be free of debris. Side gate observed self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational.

LPA reviewed 3 out 6 residents’ files to have all the required documents. Staff files were also reviewed to have current First Aid/CPR, Personnel Record, Criminal record Statement, and Health Screening. Staff were fingerprinted cleared and associated with facility.

No deficiency cited during inspection. Exit Interview conducted. The following documents are requested and
submitted to Fresno CCL by: 11/13/23. Forms requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610E, current Administrator certificate, and current liability insurance. A copy of this report was provided to Administrator, 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: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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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