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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203448
Report Date: 08/03/2023
Date Signed: 08/03/2023 02:00:15 PM


Document Has Been Signed on 08/03/2023 02:00 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:MANCILLA, DAVILYN TANTAYFACILITY TYPE:
740
ADDRESS:2226 W PEREZ CTTELEPHONE:
(559) 739-1297
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:5CENSUS: 5DATE:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Davilyn Mancilla, Licensee/AdministratorTIME COMPLETED:
02:20 PM
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On 8/3/23 at 9:26 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and met with Licensee/Administrator (LIC) Davilyn Mancilla.

LPA toured inside and outside the facility. No obstructions observed. Facility set at comfortable temperature. All bedrooms observed with sufficient furnishings and lighting. Fire extinguisher last serviced 7/14/23. Hot water measured 108.4 degrees F in the hall bathroom. Non-skid mats observed in showers. Grab bars observed for each toilet and shower. Smoke and carbon monoxide detectors tested and operational. 2-day perishables and 7-day non-perishables supply of food observed. Sharps observed locked. Chemicals observed locked in cabinet in garage. Centrally stored medication observed locked. Staff and resident records reviewed.

No deficiencies cited during the inspection.

Exit interview conducted. A copy of this report was given to Licensee, whose signature confirms receipt of this report.

The following updated forms are to be submitted to CCL within 2 weeks:

LIC500, LIC308, LIC9020, LIC610E
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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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