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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207204186
Report Date: 10/10/2023
Date Signed: 10/12/2023 09:50:01 AM

Document Has Been Signed on 10/12/2023 09:50 AM - 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:JACKSON HOUSE KENSINGTONFACILITY NUMBER:
207204186
ADMINISTRATOR:JACKSON, KIMBERLYFACILITY TYPE:
735
ADDRESS:16212 ROAD 37TELEPHONE:
(559) 645-0999
CITY:MADERASTATE: CAZIP CODE:
93638
CAPACITY: 6CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Administrator Kimberly JacksonTIME COMPLETED:
02:00 PM
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On 10/10/23 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an annual inspection. LPA was greeted and met with Licensee Kimberly Jackson. LPA explained the reason for the visit.

LPA toured the facility inside and out. LPA observed to house to be obstruction free and free from odor. Facility is licensed for 6 and currently has 4 residents. No residents were home at the time of the inspection and were all at Day Program.

LPA test the water temperature in the kitchen sink which read at 115.2 degrees F. LPA observed fire/earthquake drill log to be up to date. Fire extinguisher was last serviced 5/19/2023 and is in good standing. Facility has first aid kit in laundry room area. Smoke detectors and carbon monoxide readers were tested and in working condition.

LPA observed resident’s rooms which were clean and with proper furniture. Residents each have their own beds with closet and storage space. Facility has internet and phone landline at the facility.

LPA observed medication and sharps to be locked and inaccessible to residents. No medication errors were found at this time. All PRNs have a prescription label with instructions.

Sample of resident files were reviewed and are current. Sample of staff files were reviewed and are current.

No citations were issued at this time. Facility will be updating their disaster plan and providing a copy to LPA by 10/24/23.

Exit interview was conducted and a copy of this report was provided to Licensee Kimberly.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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