247209295-1-23-2024-24-AS-SHUT-CZS8BP-20240123212240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 247209295
Report Date: 02/03/2023
Date Signed: 01/23/2024 09:22:48 PM

Document Has Been Signed on 01/23/2024 09:22 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	PROVIDENT HEALTH CARE TAMARACK		FACILITY NUMBER:	247209295
ADMINISTRATOR:	TIU, JERRY		FACILITY TYPE:	735
ADDRESS:	1390 5TH STREET		TELEPHONE:	(209) 388-1002
CITY:	ATWATER	STATE: CA	ZIP CODE:	95301
CAPACITY: 6		CENSUS: 0	DATE:	02/03/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Maria Simon		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA Hurt arrived and was granted entry to the facility by Administrator Maria Simon . An initial application to operate a Adult Residential Facility (ARF) was submitted to the Central Applications Unit (CAU) on 11/10/2022 for a capacity of four adult residents. LPA Hurt observed the following: Structure: Facility is a one-story house with 4 resident bedrooms, 2 bathrooms, 1 staff room, 1 storage room, 1 office, family / living room, dining area and kitchen. The resident bedrooms will accommodate residents' furnishings. Signal System: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms #1-4 will accommodate 4 clients (each have their own bedroom) Bathrooms: All bathrooms have a working toilet, wash basin, and shower. Linens and Hygiene Supplies: Adequate supply of linens is stored on shelf inside staff room area. Emergency Phone Numbers, Exit Plan, and Sample Menu: Are currently posted and readily available for review in the living room.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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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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: PROVIDENT HEALTH CARE TAMARACK	FACILITY NUMBER: 247209295
	VISIT DATE: 02/03/2023

NARRATIVE

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Food Service:

Adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen and pantry.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems were hardwired and found operational.
Fire Extinguisher:
1 Fully charged and stored on wall near kitchen area
Fire Clearance:
Approved on 12/29/2022
Appliances:
Electric four burner stove with oven, refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer are located in the backyard area in the and were clean and noted to be operational. Toxins:
Will be locked away/ stored in the garage area .
Water Temperature:
Tested and recorded at 119 degrees (within regulation)
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored in locked cabinet next to dining area. Medication will be stored and locked inside locked cabinet, inside locked staff room.
Resident and Staff Files:
Records will be kept in filing area in staff room.
Reading Material, Games, Equipment, & Materials:
The facility has materials that commensurate with their plan of operation.

Continued onto 809C..

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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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: PROVIDENT HEALTH CARE TAMARACK	FACILITY NUMBER: 247209295
	VISIT DATE: 02/03/2023

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The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Unit.

Applicant was reminded of the statute that requires notification to Licensing Program Analyst within 5 business days of admitting the first resident. This notification may be done by phone, mail, email or fax.

At this time, facility has met all pre - licensing requirements of Title 22 division 6.

An exit interview was conducted with Administrator Maria Simon, and a copy of this report was provided at the time of visit.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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