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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208887
Report Date: 02/23/2023
Date Signed: 02/27/2023 09:51:16 AM


Document Has Been Signed on 02/27/2023 09:51 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:FIVE STAR ASSISTED LIVING CORPFACILITY NUMBER:
107208887
ADMINISTRATOR:OGANYAN, HASMIK JASMINEFACILITY TYPE:
740
ADDRESS:2573 W. BARSTOW AVETELEPHONE:
(559) 283-8543
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 6DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Administrator, Jasmine OganyanTIME COMPLETED:
02:18 PM
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On 2/23/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced infection control/annual visit. LPA met with Administrator, Jasmine Oganyan and discussed reason for visit. LPA was COVID pre-screened and permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms at time of visit.

Required postings including coughing/sneezing etiquette and hand washing posting observed at hand washing stations and throughout the facility. Furniture in common areas are spaced to promote physical distancing. A 2-day supply of perishable and 7-day supply of non-perishable food was observed. Bedrooms observed with required furnishings and lighting. Facility telephone was observed working A supply of PPE is located in hallway. The 30 day supply of medication is located in a locked wash room closet.



Linens, hygiene and cleaning supplies observed.. Fire Extinguisher last serviced 02/16/23. LPA requested the following updated forms by 3/2/2023: LIC 308, LIC 309, LIC 500, LIC 610D, and LIC 9020.

No deficiencies cited during todays visit. Exit interview completed with Administrator, Jasmine Oganyan. A copy of this report was given.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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