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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208997
Report Date: 12/21/2023
Date Signed: 12/22/2023 12:44:35 PM

Document Has Been Signed on 12/22/2023 12:44 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:SVS KINGSBURGFACILITY NUMBER:
107208997
ADMINISTRATOR:REYNOSO, DAWNFACILITY TYPE:
775
ADDRESS:1654 CALIFORNIA STREETTELEPHONE:
(559) 443-7119
CITY:KINGSBURGSTATE: CAZIP CODE:
93631
CAPACITY: 60CENSUS: 29DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Program Director, Myra ReyesTIME COMPLETED:
04:39 PM
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On 12/21/23 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Administrator, Myra Reyes. LPA introduced self, explained reason for visit and was permitted entry into the facility.

LPA completed a health and safety check on residents in care. LPA toured the facility. Residents observed in common areas and in activity rooms. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational on a system at time of visit. Fire extinguisher last serviced 08/18/23. Last fire drill on 11/24/23. Water temperature measured 115.3 degrees F. Program rooms observed to have the required seating and adequate lighting. Sharps/chemicals observed in locked cabinets. LPA observed sufficient seating under covered patio areas.

The following issues were observed during visit: Chemicals observed in activity room and staff break room unlocked and accessible to clients in care.

LPA requested the following documents to be submitted to CCL by 12/28/23: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

TA provided for issues listed. No deficiencies were cited during the inspection. Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with Regional Director, Dawn Reynoso and Administrator, Myra Reyes. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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