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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209296
Report Date: 06/23/2023
Date Signed: 06/26/2023 07:51:08 AM

Document Has Been Signed on 06/26/2023 07:51 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:MESCAL HOUSEFACILITY NUMBER:
277209296
ADMINISTRATOR:TINIUS, JEFFREYFACILITY TYPE:
735
ADDRESS:1722 MESCAL STREETTELEPHONE:
(480) 261-7130
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY: 6CENSUS: 0DATE:
06/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator- JeffreyTinius TIME COMPLETED:
02:00 PM
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On 6/9/2023 at 1:00 p.m. Licensing Program Analyst (LPA) B. Miranda arrived at facility to complete an announced Pre-Licensing visit. LPA met with Administrator (AD) Jeffrey Tinius. LPA toured the facility inside and out. During the tour AD verified all four bedrooms will be occupied by residents. 2 rooms have 2 beds and 2 rooms have single beds.

LPA observed all trash cans at the facility to have lids. LPA observed master bathroom shower to be cleaned, extra items in the bedrooms were removed, and bedroom window sills cleaned. AD purchased a lockable container to store medication in the fridge. LPA observed backyard path way to be clear and free from obstruction. LPA observed kitchen and found non-perishable food items to be non-expired. AD provided verification of dryer purchase and will be delivered 6/24/23.

LPA observed the following on 6/9/23 visit:
Physical plant is consistent with the facility sketch/floor plan. Fire extinguisher purchased with receipt attached, current and in good standing. Smoke & carbon monoxide detectors tested & determined to be operational.

Deficiencies were correct and no other deficiencies were found at this time.

Component III was also conducted and completed. Exit interview was conducted. Pre-licensing requirements have been met.
An exit interview was conducted with Administrator. Report LIC809 was signed on-site by Administrator and
printed copy provided.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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