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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201273
Report Date: 05/22/2024
Date Signed: 05/22/2024 02:32:14 PM

Document Has Been Signed on 05/22/2024 02:32 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:SANDOVAL HOME IIFACILITY NUMBER:
547201273
ADMINISTRATOR/
DIRECTOR:		SANDOVAL,CHRISTINEFACILITY TYPE:
735
ADDRESS:3815 S. SILVERVALETELEPHONE:
(559) 636-7628
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 6DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee Christine SandovalTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 5/22/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA was allowed entry by Licensee Christine Sandoval.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed. Sharp items and chemicals are locked under the kitchen sink. Cleaning supplies were locked and secured in laundry room. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the kitchen was last serviced on 6/23/2023 and was fully charged. Common areas were properly furnished and well-lit throughout. LPA observed unlocked paint cans in the garage. Smoke alarms and carbon monoxide tested and operational. LPA toured 3 bedrooms which are shared. LPA observed 1 live in staff bedroom. All clients’ bedroom toured and observed to be adequately furnished and lit and restrooms observed to be clean, odor free and functioning at time of visit. The exterior tour was conducted. Backyard observed to have sufficient seating. Backyard gate was self-latching and self-closing. Pool observed gated and locked. Medication was reviewed. Staff records were reviewed for good health and infection control training. All clients’ records reviewed to have updated emergency contact information. Last fire drill:4/11/2024

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22,
Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 5/29/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. Report signed on-site; and a printed copy was provided with appeal rights
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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Document Has Been Signed on 05/22/2024 02:32 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 05/22/2024 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SANDOVAL HOME II
FACILITY NUMBER: 547201273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of one paint cans observed unlocked in the gaeage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Licensee immediately removed and locked the paint gallons in the staff closet.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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