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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209355
Report Date: 06/06/2024
Date Signed: 06/10/2024 11:39:08 AM


Document Has Been Signed on 06/10/2024 11:39 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: 4DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nelly Tan - Co-LicenseeTIME COMPLETED:
11:55 AM
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On 6/6/2024, Licensing Program Analyst (LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Co-Licensee Nelly Tan and announced the purpose of the inspection. Administrator certificate is current with renewal date 1/26/2025.

LPA toured the facility inside and outside. All exits and passageways were clear and free from obstruction. LPA observed three fire extinguishers which were fully charged. Carbon monoxide and smoke detectors were operational. LPA reviewed facility emergency disaster plan and record of emergency drills. There was an adequate supply of emergency food and water, which was properly stored in the outdoor storage room. Outdoor area was free from hazards and provided covered sitting areas for residents. Common areas were clean, adequately lit, and provided seating for all residents. Facility kitchen was clean. LPA observed an adequate supply of perishable and nonperishable foodstuffs which appeared to be properly stored. Menu of meals was prominently posted in the facility common area. Detergents and cleaning supplies were secured in locked cabinets. Medications were secured in a locked storage cabinet, and medications appeared to be properly administered.

LPA toured resident bedrooms and bathrooms. Bedrooms were clean, odor-free, adequately lit, and had required minimum furnishings. Resident bathrooms were clean and odor free. All fixtures were functioning properly and hot water was within required temperature range. Bathrooms had required secure grab bars and non-skid mats. LPA reviewed staff and resident files. Files contained required records. No deficiencies were cited during the inspection. A copy of the report was provided and exit interview was conducted.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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