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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209377
Report Date: 01/12/2024
Date Signed: 02/08/2024 02:06:27 PM

Document Has Been Signed on 02/08/2024 02:06 PM - 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:BURLINGTON, THEFACILITY NUMBER:
157209377
ADMINISTRATOR:GIBSON, KALAFACILITY TYPE:
740
ADDRESS:13 SYCAMORE DRTELEPHONE:
(415) 810-0145
CITY:WOFFORD HEIGHTSSTATE: CAZIP CODE:
93285
CAPACITY: 21CENSUS: 17DATE:
01/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Administrator Kala Gibson and Regional Director Steven CruzTIME COMPLETED:
04:00 PM
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On 01/12/24, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct a case management visit based on record review of incident report submitted to the department. LPA introduced itself, announced the purpose of the visit and met with Administrator Kala Gibson and Regional Director Steven Cruz.

The purpose of today's visit is to follow up on an incident that was reported to the Fresno CCL office on 01/09/24. It was reported that on 01/05/24 at approximately 05:30PM, Resident 1 (R1) was sent out to hospital due to drinking hand sanitizer.

During today’s visit, LPA conducted interviews, toured the facility, and reviewed records. LPA obtained copies of R1’s record.

The information provided will be reviewed; a follow up case management will be conducted if necessary.

An exit interview was conducted. A copy of this report was provided to Administrator, whose signature confirm receipt of this report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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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