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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208854
Report Date: 12/29/2022
Date Signed: 01/19/2023 11:10:25 AM

Document Has Been Signed on 01/19/2023 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:HOUGHTON HOMEFACILITY NUMBER:
157208854
ADMINISTRATOR:SAYSON, SHANNONFACILITY TYPE:
735
ADDRESS:6444 HOUGHTON RDTELEPHONE:
(661) 827-8025
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 4CENSUS: 4DATE:
12/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Administrator Shannon SaysonTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) B. Miranda conducted an unannounced case management visit for incident that occurred on 12/9/22. LPA met with caregiver, and Administrator (AD) Shannon Sayson arrived shortly after. The purpose of this visit is to ensure the health and safety of the residents. Facility self- reported incidents.

LPA observed 1 (R3) of the 4 residents at the kitchen table. One other residents was in their room asleep (R1). LPA interviewed R3 (please see 812 regarding interview).

LPA toured the facility inside and out. LPA observed knives, cleaning supplies, and medication as being inaccessible to residents. LPA observed 30-day supply of PPE. LPA observed sufficient perishable and nonperishable food at the facility.

AD stated he email each resident's IPP, CPI training verification for all staff, copy of LIC 500, work schedule for November and December, and copy of SIR for 12/9/22.


No deficiencies issued. Exit interview conducted with Admin. Report provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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