275202056-7-24-2023-24-AS-VGON-CU2JJP-20230724070551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 275202056
Report Date: 07/21/2023
Date Signed: 07/24/2023 07:06:18 AM

Document Has Been Signed on 07/24/2023 07:06 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:	CIELO VISTA		FACILITY NUMBER:	275202056
ADMINISTRATOR:	MARK CASTILLO		FACILITY TYPE:	735
ADDRESS:	806 ELM AVENUE		TELEPHONE:	(831) 674-2180
CITY:	GREENFIELD	STATE: CA	ZIP CODE:	93927
CAPACITY: 40		CENSUS: 40	DATE:	07/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrative assistant, Ana Bides		TIME COMPLETED:	05:00 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	On 07/21/23, Licensing Program Analyst (LPA) V Gorban arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by administrative assistant Ana Bides, stated the purpose of the visit and was allowed entry into the facility. Administrator on record is Mark Castillo was not available to attend the visit but was notified of licensing visit. Administrator certificate # 6022513735 Expiration 11/18/24 is observed posted on the wall. LPA conducted a tour of the facility, inside and out. Facility temperature was 76 degrees F. Clients were observed attending lunch at the dining room. Facility is a 20 private rooms double occupancy shared bathroom with shower included. Clients’ bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. Fire Extinguisher was observed with a service date of 01/17/23. First aid kit was observed and contained all required items. Carbon monoxide and smoke detectors were tested and observed to be operational. Bathrooms were toured and observed to have operational lights, running water, and towels. Hot water temperature tested at 112 degrees F. Trash can with lid and hand washing postings were observed. Internet devices and a working phone line were observed to be available for residents in care. A supply of extra linens and towels were observed in the storage unit and available to clients.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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: CIELO VISTA	FACILITY NUMBER: 275202056
	VISIT DATE: 07/21/2023

NARRATIVE

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Medications were observed to be locked in med cart located in med room. Facility uses to document QuickMAR system for dispense, document and track clients’ medications. To keep track of Narcotics facility uses chart only to document, track narcotic dispenses to clients.

Cleaning supplies were observed to be in a locked cabinet in the garage. The exterior tour of back yard was conducted and found to be free from debris. A covered outdoor seating area was observed for residents in care. Side gate was self-closing and self-latching.

Clients’ files were reviewed and observed to have update emergency contact information, Admission agreement, and current medical assessment, Individual Performance Plans, Individual Behavioral Support Plans, and an Individual emergency intervention plan and needs and service plans.

LPA reviewed Administrators personnel file. Mandated Reporting requirements were provided and discussed with Administrator.

The following documents were obtained at the time if visit. LIC 500, LIC 9020, LIC 610D, Disaster Plan (facility’s emergency plan procedures). LPA requested the following be submitted to Fresno CCL by: 07/30/23: LIC 308, LIC 400, LIC 402,

An exit interview was conducted, and a copy of this report was discussed and provided for facility records. No deficiencies cited on today's visit.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

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