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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209128
Report Date: 02/08/2023
Date Signed: 02/08/2023 06:02:05 PM


Document Has Been Signed on 02/08/2023 06:02 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:A PLACE CALLED HOME RESIDENTIAL 7FACILITY NUMBER:
107209128
ADMINISTRATOR:MURCHISON, COLINFACILITY TYPE:
740
ADDRESS:2238 MONTANA AVETELEPHONE:
(559) 213-7251
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 6DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Caregiver, Nori PerezTIME COMPLETED:
09:45 AM
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On 02/08/2023, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Nori Perez, Caregiver. Administrator Collin Murchison was notified of Licensing visit over the phone.

LPA conducted a facility walk with caregiver Nori. All six residents were present during inspection. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed. LPA observed fire extinguisher served date: 02/08/22.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed five single occupant rooms and one vacant bedroom. All bathrooms are observed with securely fastened grab bars and non-skid mat. LPA observed bathrooms trash bin with lid. Hand washing posting observed by bathroom sinks.
LPA checked residents’ locked medications and reviewed residents facility files for updated information. LPA observed 30 days PPE supplies storage in a central location. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in laundry room and under kitchen sink.

No deficiencies were observed. LPA provided the source to Title 22 and PINs update information.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: A PLACE CALLED HOME RESIDENTIAL 7
FACILITY NUMBER: 107209128
VISIT DATE: 02/08/2023
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LPAs are requesting the following documents to be provided to the Fresno CCL office by 02/30/2023: Current copy
Of:

LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.


An exit interview was conducted. Report signed on-site by Nori Perez and printed copy for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC809 (FAS) - (06/04)
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