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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209327
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:09:55 PM

Document Has Been Signed on 05/09/2023 02:09 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:GROVE HOME LLC, THEFACILITY NUMBER:
547209327
ADMINISTRATOR:UNKNOWNFACILITY TYPE:
735
ADDRESS:3413 E GROVE AVETELEPHONE:
(559) 786-1819
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 0DATE:
05/09/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee/Administrator Eesaeng MartinezTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) K.Kaur conducted a Pre-licensing Inspection on this date. LPA met with Licensee Eesaeng Martinez. A tour of the facility was conducted together.

The facility has 4 designated resident bedroom, Master bedroom will be designated for live in staff. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas were properly furnished with dining tables and sofa set and well-lit throughout. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher was observed with a service date of: 3/8/2023. Smoke detectors and carbon monoxide detectors were tested and observed to be operational. The First Aid Kit was observed to have the required supplies. Medication will be kept locked cabinet in the dinning area. Knives, cleaning supplies and chemicals will be locked in the hallway closet

The tour started in the dining room and proceeded to living area/ Kitchen and resident's bedrooms. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms were properly equipped and have trash cans with a fitting lid. Hot water was tested and was 110.5 F in the bathroom. Patio has a covered sitting area, and a self-latching gate was observed in the backyard. Required postings were observed. Component III was also conducted and completed.

Exit interview was conducted, report was signed on site and a copy of the report will be provided to via email to Licensee due to technical difficulties.

Pre-licensing requirements were met.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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