<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209492
Report Date: 08/09/2024
Date Signed: 08/09/2024 11:10:00 AM


Document Has Been Signed on 08/09/2024 11:10 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:AUTUMN RIDGE ASSISTED LIVINGFACILITY NUMBER:
107209492
ADMINISTRATOR:BARAJAS, MARIAFACILITY TYPE:
740
ADDRESS:14280 WEST STANISLAUS STREETTELEPHONE:
(559) 842-7727
CITY:KERMANSTATE: CAZIP CODE:
93630
CAPACITY:54CENSUS: 27DATE:
08/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee Jonathan Johnson, Administrator Maria Barajas, Operation Manager, and Administrator 2 Mory JaimeTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) M. Yang conducted an unannounced visit to the facility for purpose of a Pre-Licensing evaluation. LPA arrived entered to the facility met Licensee Jonathan Johnson, Administrator Maria Barajas, Operation Manager, and Administrator 2 Mory Jaime. LPA conducted an announced Pre-licensing and Component III inspection for Change of Ownership. Fire clearance was granted for 50 non-Ambulatory and 4 bedridden for total of 54 capacity.

The facility has two wings: east and west. Smoke detectors and carbon monoxide detectors were observed during inspection. Fire extinguisher observed throughout the facility on each wing with service date of 06/06/24. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods. A salon and activity room were observed. LPA observed an extra supply of bed linens and personal hygiene products. Sample of residents’ bedrooms were observed to have required furnishings and lighting. Temperature maintains at 31 degrees F in refrigerator 1 and 36 degrees F in refrigerator 2. Sample of residents’ bathrooms are observed with securely fastened grab bars and non-skid mat. Bathrooms observed operational and functional. Hot water measured ranged between 107.2 degrees F to 109.9 degrees F. Facility washer and dryer observed operating during inspection. Chemicals observed stored and locked in locked closets on each wing. Delayed egress doors observed. Exterior toured and observed free of debris. Adequate outdoor seatings observed available for the residents. First aid kit was observed and contained all required items. Medications observed locked in medication cart in the medication room. A sample of resident files were reviewed to have Admission Agreements, Physician Reports, and Pre-Appraisal. A sample of staff files were reviewed to have a criminal record clearance, fingerprinted clearance, and good health screening.

Component III was conducted during today's pre-licensing visit. I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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 1