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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209194
Report Date: 12/02/2022
Date Signed: 12/05/2022 08:58:27 AM

Document Has Been Signed on 12/05/2022 08:58 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:JEFFERSON HOMEFACILITY NUMBER:
207209194
ADMINISTRATOR:POSAS, JULIA REBECCAFACILITY TYPE:
735
ADDRESS:1542 JEFFERSON AVETELEPHONE:
(559) 481-9096
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY: 6CENSUS: 4DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator-Julia PosasTIME COMPLETED:
03:45 PM
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On 12/02/2022, Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct the required Annual Infection Control Inspection. LPA was greeted by Administrator Julia Posas and was allowed entry into the facility.
LPA observed a central entry point with hand sanitizer. Census was verified to be 4. AD asked LPA Covid screening questions and temperature was taken.

LPA observed 2 of the 4 residents at the facility in common areas of the facility. The other 2 residents were at Day Program.

LPA toured facility inside and out. LPA observed Kitchen clear and free of clutter. Knives and medication were lock and inaccessible to residents. Chemicals are kept in a lock area. Facility has 2 days worth of perishable food and 7 days worth of nonperishable foods.

Facility has 4 bedrooms and 2 bathrooms. Each resident has their own room. Bedrooms were also observed with each resident having closet space and drawers.

Outside of facility was observed and exits are free of any obstructions.

Water temperature was checked and is reading 117-degree. Fire extinguishers were observed and are in good standing. Covered trash bins were observed. LPA did observe supply of PPE, AD was informed to have gowns on site. LPA will follow up if CCLD will provide gowns or not.

No deficiencies cited on today’s inspection.

Copy of 809 was provided to AD. Exit interview conducted.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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