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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208860
Report Date: 10/11/2022
Date Signed: 10/11/2022 12:41:30 PM

Document Has Been Signed on 10/11/2022 12:41 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 PLUS BOARD AND CARE HOMEFACILITY NUMBER:
107208860
ADMINISTRATOR:TIBURCIO, RAULFACILITY TYPE:
740
ADDRESS:6757 E. CHRISTINE AVENUETELEPHONE:
(559) 493-9141
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 4DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Administrator, Raul TiburcioTIME COMPLETED:
11:00 AM
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On 10/11/2022 Licensing Program Analyst (LPA) Vadim Gorban arrived unannounced for an Annual Required Inspection. LPA met with Administrator Raul Tiburcio. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Non-slid mats in showers observed. Hand washing posters were observed by the bathrooms. Bedrooms were checked. The exterior tour was conducted.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. . LPA observed facility to have a 7-day supply of non-perishable and 2-day supply of perishable food available. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Resident’s files have updated emergency contact information. Staff files reviewed or education and training.

No deficiencies were observed and cited on this visit. .

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: A PLUS BOARD AND CARE HOME
FACILITY NUMBER: 107208860
VISIT DATE: 10/11/2022
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Residential Care Facility for the Elderly (RCFE):
· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 10/30/2022
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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