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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209425
Report Date: 04/19/2024
Date Signed: 04/19/2024 12:45:59 PM


Document Has Been Signed on 04/19/2024 12:45 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:AMERICAN SENIOR LIVINGFACILITY NUMBER:
157209425
ADMINISTRATOR:JUAREZ, LINA F DIAZFACILITY TYPE:
740
ADDRESS:9003 DROVERS RUN RDTELEPHONE:
(323) 443-5786
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 0DATE:
04/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:with Licensee Lina Diaz Juarez and Licensee’s spouse Shervin Mohammadi TIME COMPLETED:
01:00 PM
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On 04/19/24, Licensing Program Analyst (LPA) Yang arrived to the facility announced to conduct the Pre licensing visit. LPA Yang met with Licensee Lina Diaz Juarez and Licensee’s spouse Shervin Mohammadi who granted LPA entry into the facility.

The facility is a 5 bedroom, and 3 bathroom home and fire clearance were granted for 3 Ambulatory and 3 Bedridden for a total capacity of 6. A fire extinguisher was observed with a service date of 01/17/24.

There are no clients present during this inspection. LPA toured the facility with Licensee. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available. Kitchen was toured and observed to have dishes, plates, and utensils. Knives kept locked in kitchen drawer. Refrigerator temperature maintained at 39.2 degrees F and freezer temperature maintained at 0 degrees F. Medications will be kept locked in kitchen shelf. Cleaning supplies and chemicals was locked in a garage cabinet. LPA observed an extra supply of bed linens and personal hygiene products. Bedrooms were observed to have the required furnishing and are ready for occupancy. Bathroom 1 hot water temperature tested at 109.6 degrees F, ranged between 107.4 to 108.1 degrees F in master bathroom, and 110.7 in private bathroom. Outside of facility toured. Exits were open and free of obstructions with self-closing side gate. Adequate outdoor seatings available for residents. LPA observed side gate to be self-latching and free of debris. First aid kit was observed and contained all required items. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Facility phone number will be (661) 493-8209.

Component III was conducted during pre-licensing visit with Applicants. I have found that applicant has met all pre licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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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