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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209377
Report Date: 11/27/2023
Date Signed: 11/27/2023 01:56:49 PM

Document Has Been Signed on 11/27/2023 01:56 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: 18DATE:
11/27/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Licensee Anthony Barbato, Administrator Kala Gibson, and Facility Manager Rufino BeltranTIME COMPLETED:
02:00 PM
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On 11/27/23, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing and
Component III inspection. LPA introduced self, stated the purpose of the visit, and met with Licensee (L1) Anthony Barbato, Administrator (A1) Kala Gibson, and Facility Manager (F1) Rufino Beltran.

The facility has 12 resident rooms. Fire clearance was granted for 14 Non-Ambulatory and 7 bedridden for total of 21 capacity. LPA toured the facility with L1, A1, and F1. Residents were observed in the dining area and in the bedroom. Facility temperature is set to 73 degrees F. Common areas were furnished and had adequate seating and lighting available. Fire extinguisher was observed throughout the facility with a service date of 04/13/23. Kitchen was toured and observed to have dishes, plates, and utensils. Refrigerator temperature maintained at 38 degrees F. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods. Medications observed locked and inaccessible to residents in the medication room. Cleaning supplies and chemicals were observed locked in a cabinet in the staff bathroom and in the staff room. LPA observed an extra supply of bed linens. All bedrooms were toured and observed to have required furnishings. Smoke detectors and carbon monoxide detectors were observed. All bathrooms were toured and observed with securely fastened grab bars and non-skid mat. Hot water measured at 108.1 degrees F in bathroom 1, 111.3 in bathroom 2, 114.4 degrees F in the bathroom 3, and 112.2 in bathroom 4. First aid kit was observed to contain all required items. Outside of facility toured and observed free of debris. Outdoor seatings were observed available for residents. Resident records were reviewed. LPA observed resident Admission Agreements, Physician Reports, and Pre-Appraisal. All staff records were reviewed and observed to have criminal record clearances.

Component III was conducted during today's pre-licensing visit.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB
in Sacramento for final review prior to license being issued.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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