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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 01/06/2023
Date Signed: 02/07/2023 02:35:09 PM


Document Has Been Signed on 02/07/2023 02:35 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:ATWATER RESIDENTIAL CARE FACILITYFACILITY NUMBER:
247209209
ADMINISTRATOR:JOHNSON, JESSICAFACILITY TYPE:
740
ADDRESS:1691 JOE SILVA AVENUETELEPHONE:
(209) 430-1688
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:5CENSUS: 4DATE:
01/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Jessica JohnsonTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced virtual POC visit with facility Administrator Jessica Johnson to verify correction of citations issued during the Case Management visit conducted on 12/07/2022.

Administrator Jessica Johnson acknowledged the $1,300 holding fee charged has not been refunded to reporting party mentioned in case management conducted on 12/07/2022 and complaint case # 24-AS-20220914194055.

Deficiency cited on 12/07/2022, Deficiency Section 87507(g)(3)(C) Any fee that is charged prior to or after admission, shall be clearly specified has not yet been cleared. Licensee has not complied with the terms of the POC by POC due date of 12/21/2022.


Exit interview conducted with Administrator Jessica Johnson and a copy of this report was provided via email.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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