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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208908
Report Date: 03/21/2023
Date Signed: 03/24/2023 02:06:50 PM


Document Has Been Signed on 03/24/2023 02:06 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/23/2023 04:29 PM

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

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This is an amended report issued on 3/21/2023.
On 3/24/23 Licensing Program Analyst (LPA) V Gorban visited facility stated above. LPA met with Assistance Administrator Jennifer Fowler , stated purpose of the visit and allowed entry in the facility followed infection prevention protocol. LPA visited facility to follow up on incident reported to department on 03/01/23. Erick Schuk was not available to assist LPA.
LPA attempted to interview resident (R1). Facility reports states R1 has dementia and unable to confirm return of the ring since R1 was not aware ring was missing in the first place. LPA contacted family member, who is R1’s daughter. Family member and responsible party (RP) confirmed that ring returned to family, and they keep in their possession.

Administrator stated that S1 last day of work was on 03/02/23. Administrator stated that S1 was terminated on the same day. Facility staff disassociated S1 from LIC500, facility roster.
Exit interview conducted, report signed by facility Assistance Administrator Jennifer Fowler and provided for facility records.

Original document was returned to LPA on 3/24/2023.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
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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