<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203448
Report Date: 11/17/2022
Date Signed: 11/17/2022 04:11:30 PM


Document Has Been Signed on 11/17/2022 04:11 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:JORDETH SENIOR CARE HOMEFACILITY NUMBER:
547203448
ADMINISTRATOR:CIANO CODANGOSFACILITY TYPE:
740
ADDRESS:2226 W PEREZ CTTELEPHONE:
(559) 739-1297
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:5CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Davilyn Mancilla, LicenseeTIME COMPLETED:
04:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/17/22 at 2:30 PM, Licensing Program Analyst (LPA) Malia Thao conducted a case management - other inspection during an inspection for complaint #24-AS-20221114142745. LPA met with Licensee/Administrator Davilyn Mancilla.

During the inspection, LPA reviewed records and made observations. Due to time contraints, LPA will return to address observations. Deficiencies may be cited during the next inspection to address the observations.

Exit interview conducted. A copy of this report was given to Licensee Davilyn Mancilla, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1