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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209089
Report Date: 03/11/2022
Date Signed: 03/11/2022 11:09:39 AM

Document Has Been Signed on 03/11/2022 11:09 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SIERRA MEADOWS BEHAVIORAL HEALTHFACILITY NUMBER:
107209089
ADMINISTRATOR:TATUM, MATTHEWFACILITY TYPE:
772
ADDRESS:1747 N JASMINETELEPHONE:
(559) 593-9801
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 3DATE:
03/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Nikki HillTIME COMPLETED:
11:21 AM
NARRATIVE
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Licensing Program Analyst (LPA) L. Xiong conducted a case management visit to the above facility. LPA met with Nikki Hill, Program Director and informed her the purpose of the visit.

Licensee modified the garage by adding an office/conference room without fire clearance. An Immediate Civil Penalty in the amount of $500 is assessed for fire clearance violation.

The following deficiencie(s) were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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 2
Document Has Been Signed on 03/11/2022 11:09 AM - It Cannot Be Edited


Created By: Les Xiong On 03/11/2022 at 10:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIERRA MEADOWS BEHAVIORAL HEALTH
FACILITY NUMBER: 107209089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2022
Section Cited
CCR
81020(a)

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81020 Fire Clearance
(a) A social rehabilitation facility shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. Licensee modified the garage by adding an enclosed office/conference room without fire clearance.
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Per facility Program Director, Nikki Hill; will bring this up to the governing board and let Community Care Licensing know of what their decision is by the POC date.
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This posed an immediate risk to the health, safety and/or personal rights of clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Les Xiong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


LIC809 (FAS) - (06/04)
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