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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203256
Report Date: 11/20/2024
Date Signed: 11/21/2024 08:51:05 AM

Document Has Been Signed on 11/21/2024 08:51 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:CARDIFFFACILITY NUMBER:
157203256
ADMINISTRATOR/
DIRECTOR:
SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:5804 CARDIFF AVENUETELEPHONE:
(667) 837-8177
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Administrator Gonzalo Cruz TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 11/20/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Administrator Gonzalo Cruz

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the kitchen was last serviced on 9/2/2024 and was fully charged. Common areas were properly furnished and well-lit throughout. Medications, First Aid, and Resident/Staff files locked in the office. Smoke alarm detectors and Carbon monoxide detectors installed and operational.

LPA toured 4 bedrooms resident rooms. All clients’ bedroom toured and observed to be adequately furnished and lit. Restrooms observed to be clean, odor free and functioning at time of visit. Extra linen and hygiene supply in the hallway closet next to bedrooms. Sharp items, cleaning supplies and chemicals are locked in the garage cabinet. The exterior tour was conducted. Backyard observed to have sufficient seating under patio. Backyard gate was self-latching and self-closing. Medication was reviewed. Staff records were reviewed for good health and training. All clients’ records reviewed to have updated emergency contact information. Last fire drill: 9/2/2024. LPA provided Acceptance and retention regulations due to 2 residents being over 60.

No deficiencies issued during this inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/26/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization
(LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan
(LIC610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; and a printed copy was provided.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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