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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209058
Report Date: 05/09/2024
Date Signed: 05/31/2024 09:45:21 AM


Document Has Been Signed on 05/31/2024 09:45 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:CHRISTINA'S HOME CAREFACILITY NUMBER:
247209058
ADMINISTRATOR:PELAYO, CHRISTINAFACILITY TYPE:
740
ADDRESS:8397 KIMBERLY WAYTELEPHONE:
(209) 485-6940
CITY:HILMARSTATE: CAZIP CODE:
95324
CAPACITY:6CENSUS: 6DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Judy BrasilTIME COMPLETED:
02:00 PM
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On 5/9/2024, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a required annual inspection. LPA met with caregiver Judy Brasil and announced the purpose of the inspection. LPA contacted Administrator Christina Pelayo via telephone. Administrator agreed that staff could sign the report on her behalf. Administrator certificate is current with renewal date of 7/12/2025.

During the inspection, LPA toured the facility inside and outside. The outdoor area was free from hazard and provided seating for all residents. All passageways and exits were clear and free from obstruction. Facility fire extinguisher has a service tag dated 11/31/2023. Smoke and carbon monoxide detectors were present and operational. LPA reviewed facility emergency disaster plan and record of emergency drills. LPA observed an adequate supply of perishable and nonperishable foodstuffs. LPA observed a supply of food and water, as well as a supply of personal protective equipment. Medications, cleaning supplies, and sharp items were secured in a closet and were inaccessible to residents. medications appeared to be administered properly.

Common areas were clean, odor free, and well-lit. LPA toured resident bedrooms and bathrooms. Bedrooms were clean, odor free, and contained all required minimum furnishings. Bathrooms were clean, contained required secure grab bars and non-skid mats, and all fixtures were functioning properly. Two residents were receiving hospice services at the time of inspection.

LPA reviewed all resident files and a sample of staff files. No deficiencies were cited during the inspection. A copy of the report was provided and exit interview conducted.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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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