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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208780
Report Date: 08/08/2023
Date Signed: 08/08/2023 02:38:00 PM

Document Has Been Signed on 08/08/2023 02:38 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:AMBITIONS - MAE CARDENFACILITY NUMBER:
547208780
ADMINISTRATOR:ISAM, TAMMYFACILITY TYPE:
735
ADDRESS:2126 N MAE CARDEN CTTELEPHONE:
(559) 739-7975
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Client Care Coordinator Jessica Mata
Administrator Tammy Isam		TIME COMPLETED:
02:55 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 8/8/23 at 9:23 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by Client Care Coordinator (C3) Jessica Mata. Administrator (ADM) Tammy Isam arrived a short time later.

LPA toured the facility. No obstructions observed. Smoke and carbon monoxide detectors tested and operational. Facility set at comfortable temperature. All bedrooms observed with sufficient furniture and lighting. Fire extinguisher last serviced 12/27/22. Sufficient linen and toiletries observed. 2-day perishables and 7-day non-perishables supply of food observed sufficient. Sharps are kept locked in kitchen drawer. Chemicals observed locked in storage unit in garage and in the laundry room cabinet. Centrally stored medication observed locked in hall closet. Staff and resident files reviewed. Administrator certification pending completion of review.

LPA observed the following deficiency:
1. Shared full bathroom observed with flooring lifted by shower, lining between shower and flooring observed cracked, door track for sliding door observed covered with dirt/debris, and the magnet locks for knife drawer and laundry detergent/cleaner cabinet observed non-operational.

A deficiency is being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with Administrator, whose signature on this form confirms receipt of these documents.

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


LIC308, LIC500, LIC9020, LIC400, LIC402, and LIC610D (new revision)
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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 4
Document Has Been Signed on 08/08/2023 02:38 PM - It Cannot Be Edited


Created By: Malia Thao On 08/08/2023 at 01:25 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: AMBITIONS - MAE CARDEN
FACILITY NUMBER: 547208780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Shared full bathroom observed with flooring lifted by shower, lining between shower and flooring observed cracked, door track for sliding door observed covered with dirt/debris, and the magnet locks for knife drawer and laundry detergent/cleaner cabinet observed non-operational, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
1
2
3
4
During the inspection, knives/sharps were moved to a different kitchen drawer that is inaccessible and laundry detergent/cleaners in cabinet were moved to the lockable storage unit in garage. Administrator will submit proof of flooring by shower repaired and lining between shower and flooring repaired in the shared full bathroom; and door track for sliding door cleaned, to CCL by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4