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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209264
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:27:52 PM

Document Has Been Signed on 05/17/2023 05:27 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 CARE A1FACILITY NUMBER:
107209264
ADMINISTRATOR:MURCHISON, DAVIDFACILITY TYPE:
740
ADDRESS:4872 STETSON RDTELEPHONE:
(559) 213-7251
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 1CENSUS: 0DATE:
05/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, David MurchisonTIME COMPLETED:
03:00 PM
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On 05/17/2023, Licensing Program Analyst (LPA) V Gorban conducted a Pre-licensing visit. LPA identified himself and discussed the purpose of the visit. LPA conducted the inspection with Administrator David Murchison.

A tour inside and outside the facility was conducted. Resident’s room have adequate furnishings and lighting and all the required furnishings (bed and dresser). Mattress and linen appeared to be in good condition. Home is fire cleared for one ambulatory resident. LPA observed a supply of extra bed linens. Bathroom is properly equipped, and trash cans has a fitting lid.
Hot water temperature was observed to be 117 degrees F. Kitchen observed to have dishes, plates, utensils. Sharps/knives and medications are locked in the kitchen. Cleaning supplies are stored. First aid kit contains all the required items. Fire extinguisher is present and was serviced on 02/09/2023. Smoke detectors and carbon monoxide are combined in one unit and operating properly.

Outside of the facility toured. Exits open free of obstruction. Gate is self-latching. No outside hazards observed.

All required postings are posted. Facility phone number will be 559- 213-7251

Component III conducted during pre-licensing inspection.

LPA have found that applicant has met all pre licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

Pre-Licensing is complete, and this facility has no deficiencies.

Exit interview conducted, report is signed and copy of the report left with facility administrator David Murchison.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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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