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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167208806
Report Date: 06/07/2023
Date Signed: 07/13/2023 05:22:26 PM

Document Has Been Signed on 07/13/2023 05:22 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:CHESTER CARE HOME 2FACILITY NUMBER:
167208806
ADMINISTRATOR:CHESTER, FLORAYFACILITY TYPE:
735
ADDRESS:1558 PEACHWOOD STREETTELEPHONE:
(559) 362-5674
CITY:LEMOORESTATE: CAZIP CODE:
93245
CAPACITY: 6CENSUS: DATE:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Licensee, Floray ChesterTIME COMPLETED:
02:19 PM
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On 6/7/23 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. Licensee, Floray Chester was contacted and arrived some time later. LPA introduced self, explained reason for visit and was permitted entry into the facility. LPA completed visit with Licensee, Direct Care Support, Andrea Orosco and Direct Care Support, Shanita Richmond.

LPA toured the facility inside and out and completed a health and safety check on residents in care.. Residents attending day program at time of visit. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 5/16/23. Last fire drill on 6/1 23. Water temperature measured 110 degrees. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closet. Sharps, chemicals and medications were located in locked cabinets.

LPA requested the following documents to be submitted to CCL by 6/16/23: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

No deficiencies were cited during the inspection. Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with Licensee, Floray Chester. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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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