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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209378
Report Date: 12/12/2023
Date Signed: 12/12/2023 10:36:31 AM

Document Has Been Signed on 12/12/2023 10:36 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:ATTENTIVE SENIOR CARE III, LLCFACILITY NUMBER:
107209378
ADMINISTRATOR:HOLLAND, PAULETTEFACILITY TYPE:
740
ADDRESS:85 W ATHENS AVE.TELEPHONE:
(559) 940-7065
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 0DATE:
12/12/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee Paulette HollandTIME COMPLETED:
10:45 AM
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The following items have been brought into compliance:
1. Theft policy and investigative procedures have been posted.
2. Grab bars have been installed in the hallway bathroom.
3. flashlights purchased, hallway night lights installed.
4. Bedroom furniture - each resident has a chair
5. Following items have been posted personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475). The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility
8. The text of this section with the heading “Rights of Resident Councils” shall be posted in a prominent place at the facility accessible to residents, family members, and resident representatives.
9. Family councils shall be provided adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, information, and newsletters.
10. Complete first aid kit observed.
11. Faucets temperature measured at 115.4 degrees.

Component III was conducted and completed. Exit interview was conducted. Pre-licensing requirements
were met. An exit interview was conducted with Licensee. Report signed on-site by Licensee and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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