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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202449
Report Date: 05/03/2024
Date Signed: 05/03/2024 11:21:50 AM

Document Has Been Signed on 05/03/2024 11:21 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:PTS FOURFACILITY NUMBER:
157202449
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, MARIANAFACILITY TYPE:
735
ADDRESS:9207 BLOSSOM TIME AVENUETELEPHONE:
(661) 496-8188
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 4CENSUS: 4DATE:
05/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Mariana Rodriguez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 05/03/24, Licensing Program Analyst (LPA) M. Yang conducted case management visit to the facility. LPA introduce self, stated the purpose of the visit, and met with Administrator Mariana Rodriguez.

The purpose of the visit is to address an incident that had occurred. The department was notified C1 had slept in the bathtub at night due to the client had urine on the client’s bed and on the client’s self.

Interview were conducted which confirms the client has not been observed sleeping in the bathtub.

No deficiency is cited during visit.

An exit interview was conducted. A copy of this report and appeal rights was provided to Administrator, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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