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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209318
Report Date: 08/28/2024
Date Signed: 08/28/2024 10:49:28 AM

Document Has Been Signed on 08/28/2024 10:49 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:SEQUOIA GROVE ASSISTED LIVING INCFACILITY NUMBER:
107209318
ADMINISTRATOR/
DIRECTOR:		HANDIAN, KEGHOUGHYFACILITY TYPE:
740
ADDRESS:1567 W MAGILL AVETELEPHONE:
(559) 449-1249
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 0DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator/ Licensee Keghougy HandianTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 8/28/2024, Licensing Program Analysts (LPAs) K. Kaur and R. Bruce arrived unannounced to conduct an annual inspection. LPAs completed a tour of the facility with Administrator/ Licensee Keghougy Handian.

The facility has no residents at this time. LPAs toured the facility with the Administrator. Tour started at Bedroom # 2. Living room observed to have an office space. Medications, first aid kit observed locked in Office Space .Tour continued to sitting room, which was equipped with adequate sofas and recliners for seating. The dining room is equipped with a table and chairs. LPAs observed a 7-day supply of non-perishable. Knives were locked in the kitchen cabinet. Cleaning supplies observed locked in the cabinet next in the laundry cabinets. The laundry area toured and observed with locks on cabinets. Residents' bedrooms were observed to be adequately furnished with beds, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available in the hallway closet. Bathrooms were clean and appropriately stocked. Water temperature was within range at 109 degrees. LPAs observed grab bars installed by toilet and non-skid mats in place. Smoke alarm detectors and Carbon monoxide detectors installed and operational. Adequate outside space for rest and recreation Sufficient seating observed under a covered patio. The fire extinguisher in entryway was serviced 6/24/2024. Backyard gate is self-closing and self-latching. Facility observed with required postings. Currently facility has no staff. Administrator records reviewed.

LPA is requesting the following documents be submitted to the Fresno CCL office once updated: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Licensee. Report signed on-site; a copy of this report was provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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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