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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206290
Report Date: 07/10/2023
Date Signed: 07/10/2023 02:15:38 PM

Document Has Been Signed on 07/10/2023 02:15 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:KAISER SPECIALIZED RESIDENTIAL TAYLORFACILITY NUMBER:
547206290
ADMINISTRATOR:MICHELLE VASQUEZFACILITY TYPE:
735
ADDRESS:2816 W TAYLOR AVETELEPHONE:
(559) 636-2590
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 3DATE:
07/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Emily Carpenter, AdministratorTIME COMPLETED:
02:30 PM
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On 7/10/23 at 12:57 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Administrator (ADM) Emily Carpenter arrived a short time later.

LPA toured the inside and outside of the facility. LPA did not observe any obstructions. Smoke and carbon monoxide detectors tested and operational. Hot water in hall bathroom measured at 113.3 degrees F. Sufficient 2-day perishable and 7-day non-perishable food supply observed. Chemicals observed in locked storage in garage. Medications observed locked in kitchen pantry. No fire clearance issues.

Due to technical difficulties, LPA will return for an Annual continuation inspection to complete the Inspection Tool. Other observations made today will be addressed in annual continuation inspection.

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

LIC500, LIC610D, LIC9020, LIC400, LIC402, All documents for change of Administrator (list of documents will be emailed to Administrator)

Exit interview conducted. A copy of this report was given to Administrator Emily Carpenter, whose signature confirms receipt of this report.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2023
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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