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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208964
Report Date: 06/21/2023
Date Signed: 06/21/2023 10:51:50 AM


Document Has Been Signed on 06/21/2023 10:51 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:CROMWELL CARE HOMEFACILITY NUMBER:
107208964
ADMINISTRATOR:BABAKHANI, ARDALAN ALEXFACILITY TYPE:
740
ADDRESS:2124 CROMWELL AVETELEPHONE:
(559) 940-7373
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
06/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator 1 Alex Babakhani and Administrator 2 Pacita Baltazar TIME COMPLETED:
11:00 AM
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On 6/21/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a Annual
visit. LPA introduced self, stated the purpose of the visit, and was granted entry. LPA met with caregiver Rodolfo Gloria. Administrator 1(A1) Alex Babakhani and Administrator 2 (A2) Pacita Baltazar was called and arrived shortly during tour. LPA toured facility with caregiver. Three residents were present upon arrival. One resident left to program during inspection. LPA conducted interviews with staff and residents.

The tour started in the kitchen into the common areas, to the resident's bedrooms, and bathrooms. The facility was observed to be at a comfortable temperature of 76 degrees F, 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. Temperature for refrigerator was maintained at 38 degrees F and freezer maintained at -1 degree F. MARs were reviewed. Medications observed kept locked in kitchen shelf. LPA toured all resident’s bedrooms and observed 4 single occupant rooms. All bedrooms were observed to have required furnishings and with adequate lightening. Bathrooms were properly equipped, and the hot water temperature was tested between 111.4 to 111.9 degrees F in bathroom 1 and between 106.2 to 106.6 degrees F in bathroom 2.

Fire extinguisher was observed with date of: 04/12/23. Last fire drill completed on 05/26/23. Cleaning supplies and chemicals stored and locked in laundry room. Outside of facility toured and observed to be free of debris. Side gate was observed self-closing and self-latching. Outside seating available for residents. Carbon monoxide and smoke detectors were tested and observed to be operational. All residents’ file reviewed to have update emergency contacts, Admission agreement, and Pre-Appraisal. Sample of staffs’ files were also reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.

No deficiencies issued during this inspection. Exit Interview conducted. LPA received copies of Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610E, and current liability insurance. A copy of this report was provided to Administrator
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
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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