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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209230
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:50:23 PM


Document Has Been Signed on 01/24/2024 03:50 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:STANFORD COTTAGE ASSISTED LIVINGFACILITY NUMBER:
107209230
ADMINISTRATOR:VASQUEZ, MARTHAFACILITY TYPE:
740
ADDRESS:2202 STANFORD AVETELEPHONE:
(559) 375-1687
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator Martha Vasquez TIME COMPLETED:
12:25 PM
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On 01/24/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit and requested to meet with Administrator. LPA met with staff Roxana Benites. Administrator Martha Vasquez was called and arrived shortly. All four resident was present during inspection.

The facility was observed to be at a comfortable temperature of 76 degree F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Temperature maintained for refrigerator at 40 degrees F. An adequate supply of perishable and non-perishable food was observed. Fire extinguisher was observed with a service date of: 12/05/2023. Medications and sharps were observed kept locked in hall closet. MARs were reviewed. Cleaning supplies and chemicals stored and locked in staff break room. All bedrooms were observed to have required furnishings and with adequate lightening. Bathrooms were properly equipped and operational. All bathrooms are observed with securely fastened grab bars and non-skid mats. Hot water temperature was tested 105.4 bathroom and 105.1 degrees F in bathroom 2. Outside of facility toured and observed to be free of debris. Side gate observed self closing and self-latching. Outdoor seating observed available for residents. All residents’ and staff file reviewed to have all the required documents. Smoke detectors were tested and observed to be operational.

No deficiency cited.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 1/30/24. Forms requested: Lic 308, current Administrator Certificate and current liability insurance. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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