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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202781
Report Date: 11/02/2022
Date Signed: 11/02/2022 06:54:25 PM

Document Has Been Signed on 11/02/2022 06:54 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:ANGELA BECERRA GAYTANFACILITY TYPE:
737
ADDRESS:777 OLYMPIATELEPHONE:
(831) 818-7981
CITY:SAN JAUN BAUTISTASTATE: CAZIP CODE:
95045
CAPACITY: 4CENSUS: 3DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Lead Registered Behavior Technician, Enrique MunozTIME COMPLETED:
03:30 PM
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On 11/02/22, Licensing Program Analysts (LPA) V Gorban unannounced Annual Required Infection Control Inspection. LPA observed a central entry point with a supply of hand sanitizer located upon entry. A sign in policy that includes documented routine symptom screening for visitors is currently being implemented to follow current visitation guidelines. LPA introduced self and stated purpose of visit , LPA met with RBT Enrique Munoz, Administrator was notified over the phone, but was unable to attend the visit.

Facility toured with Lead RBT, Registered Behavioral Technician. All four bedrooms are single occupancy. All clients bedrooms observed to be fully furnished. Clients present during today's inspection observed to be sitting in dining/activity areas watching a television, others resting in their rooms. Kitchen toured, LPA observed facility to have a 2-day of perishable and a 7-day supply of non-perishable food available. Medications are locked and secured in medication storage closet tjhat located in staff office. Clientts observed to have a 30-day supply of medication available. PPE is locked and secured and available if necessary. Fire extinguishers present with a service date of 11/01/22.

No deficiencies observed.

Exit interview conducted. Report signed on site and a copy provided to Administrator for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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: 11/02/2022
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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
· Copy of current Administrator Certificate


Please submit the above forms/information to Fresno CCL by: 11/25/2022

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.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
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