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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200867
Report Date: 07/09/2024
Date Signed: 07/23/2024 09:59:52 PM


Document Has Been Signed on 07/23/2024 09:59 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:SHEPHERD'S INNFACILITY NUMBER:
275200867
ADMINISTRATOR:WILLIAMS, LITA P.FACILITY TYPE:
740
ADDRESS:11899 CYPRESS CIRCLETELEPHONE:
(831) 632-2200
CITY:CASTROVILLESTATE: CAZIP CODE:
95012
CAPACITY:6CENSUS: DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:TIME COMPLETED:
06:00 PM
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On 7/9/24, Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a required Annual Inspection visit. LPA introduced herself, stated purpose of visit, and was allowed entrance by staff. Administrator Lita Williams was contacted, and arrived shortly after.

LPA toured the facility inside and out including entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPA observed facility to have a sprinkler system, but Administrator stated it has not been serviced for a few years. Medications are stored in a locked cabinet in the kitchen. Knives and sharp objects are secured in the kitchen. LPA observed tools to be in unlocked drawer in the kitchen. LPA observed some unlocked toxins under the sink and in a cabinet next to the sink.

Facility has 9 bedrooms, 6 of which are for residents. There are 4 bathrooms, 2 which are for residents. Residents not share bedrooms.

Fire extinguishers show charged but were last serviced 7/27/22. There are currently no smoke alarms in the facility. Administrator was unable to provide proof at this time the sprinkler system is in working condition. Carbon monoxide detector was tested and in working condition. Water temperature was checked in one resident's bathroom and read at 119.8 degree Fahrenheit.
LPA did observe some of the following deficiencies: food being stored and not properly labeled/dated, non-perishable items being kept in the garage with pest issue (droppings), medication not being properly recorded on centrally stored log, audio alarms not on, resident's room being used to access outside while throwing trash.

LPA will return at a later date to complete annual inspection and issue citations.

Exit interview was conducted and a copy of this report LIC809 was provided to Administrator Lita Williams.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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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