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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206901
Report Date: 01/23/2023
Date Signed: 01/24/2023 07:44:22 AM

Document Has Been Signed on 01/24/2023 07:44 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:A PLACE CALLED HOME RESIDENTIAL CARE 4FACILITY NUMBER:
107206901
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2842 CALIMYRNA AVETELEPHONE:
(559) 326-0953
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 5DATE:
01/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Eflida Fickle, Caregiver.TIME COMPLETED:
04:00 PM
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On 01/23/23, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and met with staff Eflida Fickle, caregiver. LPA toured facility with caregiver. Collin Murchison, designated representative was called and notified of licensing visit. All five residents were present during the inspection.

Upon entry facility staff was observed with following infection protocol. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings not observed.

LPA checked residents’ locked medications. Per designated representative 30-day PPE supplies stored at facility central location. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in the garage and under kitchen sink.

All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 6 bedrooms that are single occupant.

The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed fire extinguisher served date: 02/08/22. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.

No deficiency recorded on this visit.

Exit Interview conducted. Copy of the report will be provided to Administrator for facility records via email.

The following documents are requested and submitted to Fresno CCL by: 02/11/23. The forms: Lic 308, Lic 500, Lic 610E, Lic 808, and lease agreement.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2023
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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