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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206601
Report Date: 05/15/2023
Date Signed: 06/19/2023 12:04:30 PM

Document Has Been Signed on 06/19/2023 12:04 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:A PLACE CALLED HOME RESIDENTIAL CAREFACILITY NUMBER:
107206601
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2827 CALIMYRNA AVETELEPHONE:
(559) 322-4432
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
05/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Administrator Collin MurchisonTIME COMPLETED:
10:30 AM
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On 05/15/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with LPA met with Micah Lermen, Caregiver. Administrator Collin Murchison was called and arrived shortly and conduct tour with LPA. All six residents were present during the inspection.

The tour started in the kitchen into the common areas to the resident's rooms. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Fire extinguisher was observed with a service date of: 02/09/23. Last fire drill 4/21/23. Medications were checked and observed kept locked in kitchen cabinet. Residents’ MARS was reviewed. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 37.4 degrees F/3 degrees C. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. LPA observed six single occupant rooms. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested 117.1 degrees F. in bathroom 1 and 115.4 degrees F. in bathroom 2. Cleaning chemicals was observed stored and locked in the garage. Outside of facility toured. Adequately seating was observed outside for resident. Side gate was self-closing and free of debris. Carbon monoxide and smoke detectors were tested and observed to be operational. All residents’ file reviewed to have update Emergency contacts, Admission agreement, Pre-Appraisal form, and physician report. A sample of staff files were also reviewed to have current First Aid/CPR, Personnel Record, Criminal record Statement, and Health Screening.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 5/22/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, current Administrator certificate, and current liability insurance. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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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