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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209199
Report Date: 02/16/2023
Date Signed: 02/22/2023 10:02:32 PM


Document Has Been Signed on 02/22/2023 10:02 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:AT HAVEN HOME IIFACILITY NUMBER:
247209199
ADMINISTRATOR:BURNS, JASMINFACILITY TYPE:
740
ADDRESS:3763 N LAKE ROADTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:13CENSUS: 13DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:House Manager- Maria KnightTIME COMPLETED:
05:00 PM
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On 2/16/2023 at 2:20 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a required 1 year annual inspection. LPA was greeted by S1 and allowed entry into the facility. House Manager was at the facility and conducted the tour with LPA.

LPA observed majority of the residents in the living room which is a common area. Residents were watching TV. Other residents were in their rooms. Facility has 8 bedrooms and 7 bathrooms.

LPA toured the facility inside and out. All exits were clear and free from obstruction. Fire extinguishers are in good standing. Water temperature in the kitchen read at 106.3 degrees Fahrenheit. LPA observed all sharp objects locked and inaccessible to residents. Fire alarms system was last service 2/10/23

LPA observed kitchen as clean and free from clutter. Facility has 2 days perishable and 7 days non-perishable food items.

Facility is in compliance with infection control procedures. Covid mitigation plan was reviewed.

LPA reviewed LIC622 and MARS for the facility. LPA observed residents medication in locked cabinet. Medication is inaccessible to residents.

LPA observed facility license, administrator will send new administrator certificate and current facility sketch by 3/2/23 .Designee form is on file for House Manager. No citations were issued.

Exit interview was conducted. A copy of this report and LIC9102 was provided to House Manager.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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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