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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 12/07/2022
Date Signed: 12/08/2022 08:55:12 AM


Document Has Been Signed on 12/08/2022 08:55 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: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:
12/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee, Jessica JohnsonTIME COMPLETED:
02:00 PM
NARRATIVE
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On 12/07/2022, Licensing Program Analyst (LPA), Sarah Hurt conducted an unannounced Case Management visit, was greeted by Licensee Jessica Johnson, and announced reason for the visit.

Licensee was informed that during a recent investigation conducted by LPA, Alexandria Walton, it was observed that the facility charged a $1300 fee to hold a room in August 2022 and when the resident did not end up moving into the facility, the fee was not refunded to the responsible party (RP). This holding fee was not specified in the admission agreement as required by Title 22 regulation, as cited in the attached 809D.

The following Deficiencies are being cited Per Title 22 Regulations.

An exit interview was conducted and a copy of this report and appeal rights were provided to Licensee Jessica Johnson

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
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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Document Has Been Signed on 12/08/2022 08:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 247209209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2022
Section Cited

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Section 87507(g)(3)(C) Any fee that is charged prior to or after admission, shall be clearly specified.
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 **This requirement was not met as evidenced by review of the admission agreement provided to RP, that did not specify a $1300 holding fee.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2