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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208887
Report Date: 01/22/2024
Date Signed: 01/22/2024 04:42:24 PM


Document Has Been Signed on 01/22/2024 04:42 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: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:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Jasmine Oganyan, AdministratorTIME COMPLETED:
03:35 PM
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On 01/22/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual
Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with caregiver Henry Alsisto. LPA toured facility with caregiver. Administrator Jasmine Oganyan was called and arrived during tour. All six residents 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. Fire extinguisher was observed with a served date: 2/2023. An adequate supply of perishable and non-perishable food was observed. Medications were observed kept locked in kitchen cabinet. Knives and cleaning chemicals were observed locked under kitchen sink. Refrigerator temperature observed maintained at 28 degree F and freezer temperature maintained at -10 degree F.

Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured. All bathrooms were observed operating and functioning during
inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested between range 106.6 and 109.4 degrees in master bathroom. Hot water temperature was tested at 112.4 in bathroom. Extra linens were observed. Outside of facility toured. Side gate was observed self-closing and free of debris. Adequate outdoor seating available for residents.

Due to time constrain, LPA will return at later date for an Annual continuation inspection.

No deficiencies cited during today’s visit.



Exit Interview conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
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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