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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206666
Report Date: 08/04/2022
Date Signed: 08/04/2022 09:40:44 AM

Document Has Been Signed on 08/04/2022 09:40 AM - 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 VASSARFACILITY NUMBER:
547206666
ADMINISTRATOR:ENNIS,KRISTENFACILITY TYPE:
735
ADDRESS:4224 E VASSAR AVETELEPHONE:
(559) 622-8955
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 4DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:19 AM
MET WITH:Bernece, staff
Stacey , Administrator
TIME COMPLETED:
08:20 AM
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On 7/26/22, Licensing Program Analysts (LPAs) V. Gorban and LPM S Moua conducted an unannounced Annual Required Infection Control Inspection. LPAs allowed entrance through designated entry point. Visitor sign-in book available upon entry. LPAs conducted facility tour with Administrator Stacey.

Facility toured. Most bedrooms are single occupancy. Residents present during today's inspection observed to be participating in sitting in dining areas and taking a walk. Kitchen toured. LPA observed facility to have a 7-day supply of non-perishable food of a 2-day supply of perishable food available. Medications are locked and secured; residents observed to have a 30-day supply of medication available. PPE is locked and secured and available if necessary. Back yard and garage was toured and facility has self latching gate No obstructions observed.

Smoke detectors observed to be operational during today's inspection. Fire extinguishers present with a service date of 05/20/2022.

Administrator to submit updated required additional documents including, LIC 500 Personnel Report, and LIC 610 Emergency Disaster Supply no later than 08/18/2022



Exit interview conducted. Report signed on site and a copy provided to Licensee for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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