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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209422
Report Date: 04/08/2024
Date Signed: 04/08/2024 10:09:59 AM

Document Has Been Signed on 04/08/2024 10:09 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:FRESNO GUEST HOME #21FACILITY NUMBER:
107209422
ADMINISTRATOR/
DIRECTOR:
KUTNERIAN, ANGELICAFACILITY TYPE:
740
ADDRESS:6808 N. BACKER AVENUETELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 0DATE:
04/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Teresa LongTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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On 4/8/2024 at 9:00 am Licensing Program Analyst (LPA) B. Miranda arrived to the facility for an announced visit to conduct a pre-licensing inspection. LPA met with Staff Teresa Long and Arielle Ballard.

Facility currently has no residents with a maximum capacity of 6. Facility is a single level residential facility with 7 bedrooms and 5 bathrooms. Facility has 6 rooms allocated for residents and one for live in staff. Facility capacity is 6 and each resident will have their own room. Residents will not share rooms at the facility.

LPA toured the facility inside and out. LPA observed all fire exits to be clear and free from obstruction. LPA observed fire extinguisher to be in good standing and located in the kitchen. Laundry room is key pad locked, medication closet is located inside of the laundry room with an additional key pad lock. LPA observed first aid kit to be complete.

All rooms have proper furniture with bed, linen, lighting, drawers, night stand, and closet storage space. All bedrooms have blinds for privacy. Sufficient lighting & furnishings in common area. Facility has a living room area and an outside area with furniture for residents to interact with each other. Physical plant is consistent with the facility sketch/floor plan. Smoke & carbon monoxide detectors tested & determined to be operational.

LPA observed all trash cans to have lids. No deficiencies were noted at this time.

Component III was also conducted and completed. Pre-licensing requirements
were met. An exit interview was conducted with Staff Teresa Long and Arielle Ballard. Report signed on-site by Teresa Long and printed copy was provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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