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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209172
Report Date: 06/05/2023
Date Signed: 06/06/2023 08:09:36 AM


Document Has Been Signed on 06/06/2023 08:09 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:VALLEY SPRING MEMORY CAREFACILITY NUMBER:
247209172
ADMINISTRATOR:REYNAGA, ELIZABETHFACILITY TYPE:
740
ADDRESS:555 MILLER LANETELEPHONE:
(209) 710-4783
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:50CENSUS: 6DATE:
06/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Administrator- Elizabeth ReynagaTIME COMPLETED:
05:00 PM
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On 6/5/23 at 4:40 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced. LPA met with Administrator (AD)- Elizabeth Reynaga and explained the reason for the visit was to amend the original report.

At 4:46 p.m. LPA collected the original report from AD and printed new amended report.
LPA did not conduct tour since the visit was strictly to provide amended report and collect original report.
Due to AD Krista Willson not being available AD Elizabeth signed on her behalf.


Exit interview was completed and copy of this report was provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
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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