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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200310
Report Date: 06/27/2023
Date Signed: 06/27/2023 10:52:58 AM

Document Has Been Signed on 06/27/2023 10:52 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:LAKE ISABELLA RESPITE CENTERFACILITY NUMBER:
157200310
ADMINISTRATOR:MCANALLY, KIMBERLYFACILITY TYPE:
775
ADDRESS:6405 LAKE ISABELLA BOULEVARDTELEPHONE:
(661) 665-8871
CITY:LAKE ISABELLASTATE: CAZIP CODE:
93240
CAPACITY: 20CENSUS: 1DATE:
06/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Otilia Benavidez, AdministratorTIME COMPLETED:
11:15 AM
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On 06/27/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduce self, state the purpose of the visit and met with Administrator Otilia Benavidez. No clients were present during the inspection. LPA completed a tour program area with Administrator.

Area used by day program was observed to be clean & in good repair. Sufficient seating & lighting available. Facility was observed with a sufficient supply of a variety of activity supplies on site and locked in cabinet. Hazardous items are maintained in locked cabinets. PPE supplies was observed. Meals are provided through the community center kitchen which serves meals to all persons in attendance at the center, including participants in this day program.Water in restroom sink is on an automated no-touch system and observed bathroom function properly. First aid kit maintained in the program area with required items.



Staff files was reviewed to have current First Aid/ CPR and fingerprinted clearance. Client file was reviewed. Client in current attendance do not require any assistance with any medications. Client files were observed to have current emergency contact and Admission agreement.

NOTE: This day program is conducted in a room contained within a community center. This day program currently operates at this location only on the 2nd and 4th Thursdays of the month from 9am to 2:30pm.



Exit Interview conducted. LPA received copies of Lic 308, Lic 309, Lic 500, Lic 610D, Lic 9020, current Administrator certificate, and current liability insurance. The following updated forms were requested to be submitted to CCL by 07/03/23: Lic 9283. A copy of this report was provided to the Administrator, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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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