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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209290
Report Date: 03/05/2024
Date Signed: 03/06/2024 08:09:52 AM


Document Has Been Signed on 03/06/2024 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:A GOLDEN CAREFACILITY NUMBER:
247209290
ADMINISTRATOR:KALINGA, ADELINAFACILITY TYPE:
740
ADDRESS:892 VALPARAISO COURTTELEPHONE:
(408) 896-1531
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:6CENSUS: 3DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Petronila Woods - AdministratorTIME COMPLETED:
05:05 PM
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On 3/5/2024, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a required annual inspection. LPA met with Administrator Petrolina Woods and announced the purpose of the inspection. Administrator certificate was current at the time of inspection. There were three residents residing in the home, one of whom is receiving hospice services.

LPA toured the facility inside and outside. Pathways and exits were clear and free from obstruction. Smoke-detectors and carbon-monoxide detectors were present and operational. Facility fire extinguisher was recently serviced. Medications were secured in locked cabinet, and medications appeared to be administered properly. The fence had a self-locking latch mechanism and both pool gates were locked. There was adequate outdoor seating for residents.
Common areas were clean, adequately furnished, and adequately lit. Resident bedrooms were clean and had required minimum furnishings. Resident bathrooms were clean, had required secure grab bars and non-skid mats, and water temperature was within required temperature range. Sharp items were secured in a locked drawer in the kitchen. LPA reviewed facility plan of operations and emergency disaster plan. LPA observed a sufficient supply of personal protective equipment and emergency food supply. Resident and staff files were reviewed. Files contained required documents and records.

No deficiencies were cited during the inspection. Exit interview was conducted with the administrator. A copy of the report was provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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