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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208930
Report Date: 07/07/2023
Date Signed: 07/31/2023 04:20:46 PM


Document Has Been Signed on 07/31/2023 04:20 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:WINDHAM, THEFACILITY NUMBER:
107208930
ADMINISTRATOR:EARLEY, JOHNFACILITY TYPE:
740
ADDRESS:1100 E SPRUCE AVETELEPHONE:
(559) 449-8070
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:88CENSUS: 77DATE:
07/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Administrator, John EarleyTIME COMPLETED:
03:30 PM
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 On 7/07/23, Licensing Program Analyst (LPA) V Gorban unannounced visited facility stated above to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to speak with administrator. John Earley, Administrator (AD) assisted LPA during annual inspection visit.

LPA and AD toured facility inside and out. Facility appeared clean with no obstruction or fire clearance issues. Fire extinguishers serviced on 11/08/22. Facility temperature appeared to be at comfortable level of 73 degrees.
Facility practicing Infection prevention, signs are posted through the facility. Hand sanitizer was readily available to residents and visitors. Common bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sinks. Bedrooms are single occupant. 77

LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Staff records were reviewed for good health and elderly training . Facility staff observed assisting residents in polite manner. Residents were observed enjoying nice weather outside on the patio. Resident’s files have updated emergency contact information and physician report.

LPA is requesting the following documents be submitted to the Fresno CCL office by 07/10/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), and Residents roster.

No deficiencies issued during today's inspection.

An exit interview was conducted. A copy of this report was signed and provided to Administrator John Earley for facility records.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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