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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209324
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:59:16 PM


Document Has Been Signed on 05/16/2023 03:59 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:GROVE, THEFACILITY NUMBER:
107209324
ADMINISTRATOR:BREWER, NORSHELLFACILITY TYPE:
740
ADDRESS:7444 NORTH CEDAR AVETELEPHONE:
(801) 815-0808
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:130CENSUS: 57DATE:
05/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Norshell BrewerTIME COMPLETED:
01:00 PM
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On 05/16/23, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Pre-licensing visit. LPA identified himself and discussed the purpose of the visit. LPA conducted the inspection with facility Administrator (AD) Norshell Brewer .

An inside and outside tour of the facility was conducted with AD. Resident’s each room 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 110 (one hundred and ten) ambulatory and twenty bed ridden residents. LPA observed a supply of extra bed linens. Bathrooms were properly equipped, and trash cans had a fitting lid.
Hot water temperature was observed to be 116 degrees F. Kitchen observed to have dishes, plates, utensils. Sharps/knives and medications are locked in the kitchen. Cleaning supplies are stored. First aid kit contains all the required items. Fire extinguisher is present and was serviced on 10/10/22. Smoke detectors and carbon monoxide are combined in one unit and were operating properly.

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

All required postings are posted. Facility phone number will be 559- 325-8170

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 left with Norshell Brewer.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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