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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208951
Report Date: 04/28/2023
Date Signed: 04/28/2023 11:46:16 AM

Document Has Been Signed on 04/28/2023 11:46 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:BUENA VISTA MANOR ARF INC.FACILITY NUMBER:
157208951
ADMINISTRATOR:BAGUIO, MIAFACILITY TYPE:
735
ADDRESS:11126 VISTA DEL VALLE DRIVETELEPHONE:
(661) 885-7838
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 6DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Supervisor Walter Rios and Licensee Sheila Bagsby TIME COMPLETED:
12:00 PM
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On 04/28/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA greeted by Supervisor (S1) Walter Rios and was granted entry into the facility. Temperature checked and visitor log was observed upon arrival. LPA introduced self and stated the purpose of the visit. Licensee (L1) Sheila Bagsby was called and arrived shortly. LPA conducted tour with L1 and S1. All six clients were present when inspection began. Three clients left to appointment later during inspection.

The tour started in the common areas, into the kitchen and to resident's rooms.

LPA observed COVID-19 related signs. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Facility was observed at temperature 71 degree F. Fire extinguisher was observed with a service date of: 01/10/23. Fire drill last completed 04/20/23.

An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 40 degrees F and freezer temperature at 0-degree F. Cleaning supplies and chemicals are kept in locked under kitchen sink and hall closet.LPA observed 2 shared residents’ bed to be at least 6 feet apart and 2 single occupant rooms.

Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms were properly equipped. Hot water temperature was tested at 105 degrees F and range at 105.1 and 105.3 in shared bathroom.Trash can with lid and hand washing postings was observed.

Outside of facility toured. Side gate was self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. LPA observed medications locked in medication cabinet in the common area.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BUENA VISTA MANOR ARF INC.
FACILITY NUMBER: 157208951
VISIT DATE: 04/28/2023
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A sample of clients’ file reviewed to have update Emergency contacts, Admission agreement, Pre-Appraisal form, MARs, and Safeguards Cash resource and Physician report. A sample of staff files were also reviewed to have current First Aid/CPR, Personnel Record, Health Screening, and Fingerprint clearance. First aid kit was observed and contained all required items.

No deficiencies issued during this inspection.

Exit Interview conducted.

The following documents are requested and submitted to Fresno CCL by: 5/05/23. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610D, Lic 9020, control of property, and current Administrator Certificate. A copy of this report was provided to Licensee, whose signature on this form confirms receipt of these report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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