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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 240407470
Report Date: 05/08/2024
Date Signed: 05/15/2024 10:09:00 PM

Document Has Been Signed on 05/15/2024 10:09 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:KINGS VIEW WORK EXPERIENCE CENTER IIFACILITY NUMBER:
240407470
ADMINISTRATOR/
DIRECTOR:		KALEMBER, SAMUELFACILITY TYPE:
775
ADDRESS:703 "I" STREETTELEPHONE:
(209) 826-8118
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY: 60CENSUS: DATE:
05/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Program Director- Irma TorresTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 5/8/24 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit. LPA met with Program Director Irma Torres to review an incident that on 4/22/24 with C1.

LPA collected the following documents while at the facility: C1's IPP from 4/2023, facility incident report for the incident regarding C1 on 4/22/24, and C1's admission agreement.

LPA is requesting recent training prior to 4/22/24 for clients with wheelchairs, April's staff schedule, staff roster with contact information, C1's current physician report, C1's needs and service plan, and client roster for 4/22/24. Documents are due by 4/15/24.

No deficiencies were noted at this time. An unannounced follow-up case management visit will be conducted at a later date.

Exit interview was conducted and a copy of this report LIC809 was provided to Program Director Irma Torres.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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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