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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202604
Report Date: 10/04/2023
Date Signed: 10/04/2023 05:04:25 PM

Document Has Been Signed on 10/04/2023 05:04 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:REINDOLLAR ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
275202604
ADMINISTRATOR:ADLER, WENDYFACILITY TYPE:
735
ADDRESS:301 REINDOLLAR AVETELEPHONE:
(831) 372-8002
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 4CENSUS: 4DATE:
10/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:28 PM
MET WITH:Administrator Wendy AdlerTIME COMPLETED:
05:00 PM
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On 10/4/2023 at 3:28 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management inspection - incident inspection. LPA explained reason for inspection and met with Administrator (AD) Wendy Adler.

On 10/3/23, CCL received an Incident Report from the facility reporting R1’s behaviors towards staff. Facility previously submitted SIRs regarding R1’s behaviors towards staff. Administrator stated R1 has been at the facility for the past four years and has displayed behaviors since then. Incident report was revised, corrected, and given to LPA at the facility. LPA reviewed R1's current IPP which indicates R1 is to have a 1:1 staff member to meet supervision, care, and training needs.

LPA conducted interviews and reviewed records. LPA obtained a copy of R1's IPP and staff schedule for 10/1/23-10/7/23.

Administrator will provide Staff Roster, and current staff training for S1 & S2, copy of request for 1:1 funding, weekly direct care staff schedule by 10/6/2023.

Once all verification is received LPA will reviewed and if follow-up is need LPA will return at a later time.

Exit interview was conducted and a copy of this report was provided to Administrator Wendy Adler.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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