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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209005
Report Date: 11/03/2023
Date Signed: 11/03/2023 11:57:16 AM

Document Has Been Signed on 11/03/2023 11:57 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:MARTINEZ RESIDENCEFACILITY NUMBER:
547209005
ADMINISTRATOR:MARTINEZ, EESAENGFACILITY TYPE:
735
ADDRESS:3527 W OAKRIDGE AVETELEPHONE:
(559) 608-5188
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Eesaeng Martinez, Licensee/AdministratorTIME COMPLETED:
12:15 PM
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On 11/3/23 at 9:26 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee/Administrator (LIC) Eesaeng Martinez arrived a short time later. No residents were present during the inspection.

LPA toured the facility and did not observe any obstructions. Smoke and carbon monoxide combo detector tested and operational. All bedrooms observed with sufficient furnishings and lighting. Food supply was checked. Cleaning supplies checked and observed locked in closet. Sharps observed inaccessible in medication cabinet. Medications observed locked and inaccessible. Sample of resident and staff files reviewed. Administrator certificate pending recertification, certification #: 6051208735.

No deficiencies cited during this inspection.

An exit interview was conducted. A copy of this report was left with Licensee, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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