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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202781
Report Date: 12/18/2024
Date Signed: 12/19/2024 05:43:51 AM

Document Has Been Signed on 12/19/2024 05:43 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:BAUTISTA HOMEFACILITY NUMBER:
355202781
ADMINISTRATOR/
DIRECTOR:		MITCHELL GUEVARAFACILITY TYPE:
737
ADDRESS:777 OLYMPIATELEPHONE:
(831) 818-7981
CITY:SAN JAUN BAUTISTASTATE: CAZIP CODE:
95045
CAPACITY: 4CENSUS: 3DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:24 AM
MET WITH:Director of Operations David SandhuTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 12/18/2024, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured the facility with lead RBT Maria Roman. Director of Operations David Sandhu was notified and was able to attend the visit. Administrator Dora Rodriguez, certification number 6065609735 and expiration date 01/18/2025 was notified of Licensing visit and was able to attend it.

The facility was observed to be at a comfortable temperature, of 69 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. During the visit the two out of four facility clients were present. Department phone number and infection prevention information signs were posted thought the facility.

Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

A fire extinguisher was observed with service date of 10/22/2024. Last fire drill was recorded on 12/02/2024. Private clients’ bedroom observed to be at comfortable temperatures. The bathroom’s water temperature was tested and recorded reading of 104 degrees F.

Medications records storage observed to be locked in a cabinet in a hallway. Cleaning supplies were observed to be in a locked cabinet in the storage it the laundry room. An outdoor seating area was observed operational for clients in care.

Report continues on attached LIC809-C
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BAUTISTA HOME
FACILITY NUMBER: 355202781
VISIT DATE: 12/18/2024
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LPA reviewed staff and clients’ files. No deficiencies were observed and cited during this visit.
Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Residential Facility (ARF):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents



Please submit the above forms/information to Fresno CCL by: 12/25/2024

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.


Exit interview conducted. A report was signed, and a copy of this report was provided for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
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