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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206785
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:21:44 PM

Document Has Been Signed on 04/24/2023 01:21 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:PETERSON RESIDENTIALFACILITY NUMBER:
107206785
ADMINISTRATOR:O'DONNELL, CAROLFACILITY TYPE:
740
ADDRESS:455 S. KONATELEPHONE:
(559) 492-2189
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 4DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Licensee Carol O'DonnellTIME COMPLETED:
01:30 PM
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On 04/24/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA greeted by Licensee (L1) Carol O'Donnell and was granted entry into the facility. LPA introduced self and stated the purpose of the visit. LPA conducted tour with L1. All four residents were present during inspection.

The tour started in the kitchen into the common areas to 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: 11/08/23. LPA observed COVID-19 related signs. LPA observed in laundry room medications kept locked in medication cart. An adequate supply of perishable and non-perishable food was observed.Refrigerator temperature maintained at 37 degrees F and freezer temperature at 0-degree F. Cleaning supplies and chemicals are kept in locked in laundry room. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. LPA observed 2 shared residents’ bed to be at least 6 feet apart. Bathrooms were properly equipped, and the hot water temperature was tested 110.2 degrees F. Trash can with lid and hand washing postings was observed. Carbon monoxide and smoke detectors were tested and observed to be operational. Outside of facility toured. Side gate was self-closing and self-latching.All clients’ file reviewed to have update Emergency contacts, Admission agreement, Pre-Appraisal form, and physician report. All staff's files were also reviewed to have current First Aid/CPR, Personnel Record, and Health Screening. First aid kit was observed and contained all required items.



No deficiencies issued during this inspection.Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 5/01/23. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610E, Lic 9020, Lic 9282, current liability insurance, and current Administrator Certificate. A copy of this report was provided to Licensee, whose signature on this form confirms receipt of these report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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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