<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208997
Report Date: 12/06/2022
Date Signed: 12/30/2022 11:01:48 AM

Document Has Been Signed on 12/30/2022 11:01 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:SVS KINGSBURGFACILITY NUMBER:
107208997
ADMINISTRATOR:REYNOSO, DAWNFACILITY TYPE:
775
ADDRESS:1654 CALIFORNIA STREETTELEPHONE:
(559) 443-7119
CITY:KINGSBURGSTATE: CAZIP CODE:
93631
CAPACITY: 60CENSUS: 21DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Program Director, Myra ReyesTIME COMPLETED:
03:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/06/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced infection control/annual visit. LPA introduced self and met with Program Director, Myra Reyes. LPA was COVID pre-screened at entry into facility but was not asked to sign into visitor log. LPA toured facility and completed health and safety check on clients in care. Currently clients are in the community, in facility and home programming. 6 clients observed in activity room having lunch.

LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. Infection Control Plan has been submitted.

Required postings of signs to include hand washing, coughing/sneezing etiquette and physical distancing were not observed throughout the facility. Staff observed with face coverings. Covered trash bins and a supply of PPE observed. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying. Water temperature at 110 degrees F in the kitchen and break room and 108 degrees F in the art room. Fire extinguishers last serviced 9/19/22. Personnel files reviewed. Staff training, First Aid/CPR documented and current.

LPA requested the following updated forms by 12/09/22: LIC 308, LIC 309, LIC 500, LIC 610D, and LIC 9020.

Through LPA observation of documentation and interviews with staff, the required infection control practices were found to be in compliance. No deficiencies cited during today's inspection. Exit interview completed with Program Director, Myra Reyes. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1