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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247202941
Report Date: 05/18/2023
Date Signed: 05/18/2023 02:32:54 PM

Document Has Been Signed on 05/18/2023 02:32 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:DAVIDSON HOMEFACILITY NUMBER:
247202941
ADMINISTRATOR:DAVIDSON, RHONDAFACILITY TYPE:
735
ADDRESS:3328 COLUMBIA DRIVETELEPHONE:
(209) 626-5014
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY: 6CENSUS: 6DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Administrator Rhonda DavidsonTIME COMPLETED:
02:45 PM
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Originally on 4/19/23 Licensing Program Analyst B. Miranda created LIC809 for unannounced annual inspection. Report was not successfully saved. LPA returned to facility 5/18/23 at 2:30 p.m.to generate report and give copy to Administrator Rhonda Davidson.

On 4/19/2023 at 12:00 p.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an Annual Inspection. LPA was greeted and allowed entry into the facility by Administrator (AD) Rhonda Davidson, LPA explained the reason for her visit.

Facility currently has a census of 6, with 6 bedrooms, & 2 bathrooms. One room is shared and the other 4 residents have their own rooms.

LPA toured the facility inside and out. Entry way of the facility was clear and free from obstructions. Smoke alarms and carbon monoxide readers were checked and in working condition. Fire extinguishers were last serviced 1/4/2023 and are in good standing. Water temperature was checked in the kitchen and read at 110.8 degrees Fahrenheit.

Kitchen was toured, LPA observed kitchen to be clean and free from clutter. LPA observed 7 days’ worth of non-perishable food items and 2 days’ worth of perishable food items. Knives were locked away and inaccessible to residents.

Medication, resident profiles, & staff profiles were locked away and inaccessible to residents.

Cleaning supplies were stored and inaccessible to residents.

LPA observed resident’s bedrooms, bedrooms had proper furniture and storage space.

LPA observed outside of the facility. Exits were clear and free from obstruction

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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