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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209399
Report Date: 10/30/2023
Date Signed: 10/30/2023 10:45:46 AM


Document Has Been Signed on 10/30/2023 10:45 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:DEL MONTE CAREFACILITY NUMBER:
277209399
ADMINISTRATOR:CABUCO, KAYFACILITY TYPE:
740
ADDRESS:1221/1229 DAVID AVETELEPHONE:
(919) 439-8488
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:65CENSUS: 22DATE:
10/30/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Kay Cabuco - LicenseeTIME COMPLETED:
11:00 AM
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On 10/30/2023, Licensing Program Analyst(LPA) D. Ayers arrived at the facility to conduct an announced Pre-Licensing Inspection. LPA met with Licensee/Administrator Kay Cabuco.

LPA met with Licensee 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 extinguishers were present and 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. Medications were secured in a locked medication room. The fences had self-latching mechanisms and there were no outdoor hazards. There is adequate outdoor covered seating for residents. LPA reviewed facility plan of operations and emergency disaster plan.

Pre-Licensing is complete and this facility has no deficiencies. Licensee 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: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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