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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167208258
Report Date: 08/31/2022
Date Signed: 08/31/2022 12:40:51 PM

Document Has Been Signed on 08/31/2022 12:40 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:LINDSEY B/C HOMEFACILITY NUMBER:
167208258
ADMINISTRATOR:LINDSEY, SHEILA COXFACILITY TYPE:
735
ADDRESS:9573 HOME AVETELEPHONE:
(559) 582-6579
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY: 5CENSUS: 3DATE:
08/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Sheila Cox LindseyTIME COMPLETED:
01:00 PM
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On 8/31/2022, Licensing Program Analysts (LPAs) V. Gorban and K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced selves, stated the purpose of the visit, and was granted entry to the facility by Administrator Sheila Cox Lindsey.

Visitor log-in/temperature check station was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff was observed with mask covering.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. Sharps, chemicals, and cleaning supplies were locked in administrator room. PPE were observed in a laundry room. A 2-day supply of perishable and 7-day supply of non-perishable food was observed to be properly stored and labelled. Fire extinguisher was observed with a purchase date of: 04/08/2022. Resident's Bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Sample of residents file was reviewed for emergency contact. Staff files were reviewed for infection control training, first aid , and good health.

No deficiencies were observed.

LPAs are requesting the following documents be submitted to the Fresno CCL office by 09/07/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D) , Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020).

An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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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