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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209323
Report Date: 10/03/2023
Date Signed: 10/03/2023 12:37:56 PM

Document Has Been Signed on 10/03/2023 12:37 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:SEQUOIA GROVE ASSISTED LIVING, INCFACILITY NUMBER:
107209323
ADMINISTRATOR:KEGHOUHY HANDIANFACILITY TYPE:
740
ADDRESS:787 E. MINARETS AVETELEPHONE:
(559) 449-1249
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 6CENSUS: 4DATE:
10/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Administrator, Keghouhy Handian TIME COMPLETED:
11:40 PM
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On 10/03/23, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Pre-licensing visit. LPA met with Licensee, Keghouhy Handian, certification number 6018226740, expiration date 07/30/2024 and discussed the purpose of the visit.
LPA began the tour at the entrance of the facility that has one entrance point. LPA toured the inside and outside of the facility. LPA observed no obstruction to emergency exit from back yard of the facility on west sides.
The facility was observed at a comfortable temperature of 78 degrees Fahrenheit, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas furnished and well-lit throughout. LPA observed the kitchen to be absent of any trash or debris, sharp objects are secured and inaccessible to residents. A two-day supply of perishable and seven-day supply of non-perishable food were observed.
Medications and chemicals were kept locked in separate cabinets. Resident’s all four individual bedrooms were observed to be furnished with bed, dresser, night stand, and overhead lightning. Mattresses, box springs, sheets, and linens, were absent of any tears and stains.
Bathrooms and showers were equipped with non-skid mats and securely fastened grab bars. Bathroom water temperature was tested at 105 degrees Fahrenheit. Towels, linens, and personal hygiene supplies were observed in storage. There are no bodies of water outside.

All Fire extinguishers are current with service date of 04/17/2023. Carbon monoxide and smoke detectors were observed to be operational. First Aid Kit was checked and observed to have the required supplies. Emergency exit plan, required phone numbers, and required postings were observed. A working facility telephone number (559-449-1249) was present and functional. Email: gmcarehome@aol.com

Component III was reviewed with Licensee and Administrator.

No deficiencies were observed on this visit. Report will be submitted Centralize Application Bureau for record and further processing of application.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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