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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209322
Report Date: 05/25/2023
Date Signed: 05/25/2023 01:37:18 PM

Document Has Been Signed on 05/25/2023 01:37 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:AAA RESIDENTIAL ELDERLY RETREAT #3FACILITY NUMBER:
157209322
ADMINISTRATOR:DILLARD, SHEILAFACILITY TYPE:
740
ADDRESS:4825 KENNY STREETTELEPHONE:
(661) 213-6798
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: 0DATE:
05/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Licensee Sheila DillardTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) K.Kaur conducted a Pre-licensing Inspection on this date. LPA met with Licensee Sheila Dillard. A tour of the facility was conducted together. This is a new facility with no residents in care. The facility was observed to be at a comfortable temperature, clean, and in good repair. No passageway obstructions or fire hazards were observed inside or outside. Common areas were properly furnished and well-lit throughout. The dining room is equipped with a table and chairs, living room is equipped with adequate sofas and chairs for residents, adequate outside space for rest and recreational under a covered patio. Gate is self-closing and self-latching.

Perishable and non-perishable food supply appeared adequate. Knives will be locked in the Hallway closet
along with medication and first aid kit. Cleaning and Chemical supplies will also be kept locked in the hallway closet with extra overflow in the garage. Residents' bedrooms were observed to be adequately furnished with bed, dresser, folding chair and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available. Hot water temperature measured at 115 degrees F. Carbon monoxide and smoke alarm detectors installed and operational. Facility has designated one bathroom for residents which has Grab bars installed in shower. Toilet equipped with toilet safety rail. Non-skid mats in place, hand soap and paper towels available for use. Trash cans with tight fitting lids are in place. Second bathroom in bedroom will be used by staff. Fire extinguisher was serviced and fully charged. Complaint poster posted, resident council info posted, residents' rights posted; emergency disaster plan posted.

Component III was completed by Licensee. 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: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
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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