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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202781
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:18:57 PM

Document Has Been Signed on 02/27/2023 04:18 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:BAUTISTA HOMEFACILITY NUMBER:
355202781
ADMINISTRATOR:MITCHELL GUEVARAFACILITY TYPE:
737
ADDRESS:777 OLYMPIATELEPHONE:
(831) 818-7981
CITY:SAN JAUN BAUTISTASTATE: CAZIP CODE:
95045
CAPACITY: 4CENSUS: 3DATE:
02/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Super Lead, Mayra GarciaTIME COMPLETED:
12:00 PM
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On 02/27/23, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit. LPA introduced self and was allowed entrance by staff. LPA met with Super Lead Mayra Garcia and stated reason for visit.

LPA arrived at the facility to conduct case management visit to relay information about Immediate Exclusion order for Staff (S1). LPA verified with ED that S1 has not worked in facility. Super Lead responded that S1 has not been with the facility. Administrator, Mitchell Guevara was advised an exclusion has been ordered and issued by the Department and provided an exclusion order document for the S1. Per Super Lead S1 was never made to facility or placed on work schedule yet. Administrator and Super, Lead was advised to disassociate S1 from facility roster and guardian.

No deficiencies sited during this Case Management visit. An exit interview was conducted, and report signed on-site, and a copy of report will be provided to Super Lead for the facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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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