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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209303
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:49:54 PM

Document Has Been Signed on 07/26/2023 02:49 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:PSALMS 23 LOVING CARE RESIDENTIAL IIIFACILITY NUMBER:
107209303
ADMINISTRATOR:COOLEY, I'ISHAFACILITY TYPE:
735
ADDRESS:441 W ALLUVIAL AVETELEPHONE:
(559) 270-3822
CITY:PINEDALESTATE: CAZIP CODE:
93650
CAPACITY: 4CENSUS: 0DATE:
07/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, I'Isha CooleyTIME COMPLETED:
01:30 PM
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On 07/26/23, Licensing Program Analyst (LPA) V Gorban conducted announced Pre-licensing visit. LPA identified himself and discussed the purpose of the visit. LPA conducted the inspection with Administrator I’Isha Cooley, Certificate number 600726735, with expiration date 10/22/2024.

A tour inside and outside the facility was conducted. Two resident’s rooms have adequate furnishings and lighting and all the required furnishings (bed and dresser). Mattress and linen appeared to be in good condition. Home is fire cleared for one ambulatory resident. LPA observed a supply of extra bed linens and towels. Bathroom is properly equipped, and trash cans has a fitting lid.

Hot water temperature was observed to be 112 degrees F. Kitchen observed to have dishes, plates, utensils. Sharps/knives and medications are locked in the kitchen. Cleaning supplies are stored and locked in the bathroom. First aid kit contains all the required items. Fire extinguisher is present and was serviced on 01/05/2023. Smoke detectors and carbon monoxide are tested operating properly.

Outside of the facility toured. Exits open free of obstruction. Gate is self-latching. No outside hazards observed.

All required postings are posted. Facility phone number is 559- 981-2497.

Component III conducted during pre-licensing inspection.

LPA have found that applicant has met all pre licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

Pre-Licensing is complete, and this facility has no deficiencies.

Exit interview conducted, report is signed and copy of the report provided for facility records.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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