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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209355
Report Date: 06/19/2023
Date Signed: 06/20/2023 08:11:21 AM


Document Has Been Signed on 06/20/2023 08:11 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:SPRINGFIELD VILLA, LLCFACILITY NUMBER:
277209355
ADMINISTRATOR:IBALIO, JANILANEFACILITY TYPE:
740
ADDRESS:97 SPRINGFIELD RDTELEPHONE:
(831) 239-6609
CITY:MOSS LANDINGSTATE: CAZIP CODE:
95039
CAPACITY:6CENSUS: 0DATE:
06/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Janilane Ibalio - AdministratorTIME COMPLETED:
10:50 AM
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On 6/19/2023, Licensing Program Analyst(LPA) D. Ayers arrived at the facility to conduct a Pre-Licensing Inspection. This visit was announced and coordinated with Licensees Janilane Ibalio and Nelly Tan.

LPA met with Licensees and toured the facility inside and outside. Pathways and doors were clear and free from obstruction. Smoke-detectors and carbon-monoxide detectors were present and operational. Facility fire extinguisher was recently serviced. Facility was clean and odor free. Common areas were clean, adequately furnished, and adequately lit. Resident bedrooms were clean and had required minimum furnishings. Resident bathrooms were clean, had required secure grab bars and non-skid mats, and water temperature was within required temperature range. Sharp items were secured in a locked drawer in the kitchen. A locked cabinet is prepared to store resident medications. The fence had a self-latching mechanism and there were no outdoor hazards. There is adequate outdoor seating for residents. LPA reviewed facility plan of operations and emergency disaster plan.

Pre-Licensing is complete and this facility has no deficiencies. Licensees completed Component III. Exit interview was conducted with the Licensees. A copy of the report was provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
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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