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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209325
Report Date: 06/06/2023
Date Signed: 06/06/2023 11:24:21 AM

Document Has Been Signed on 06/06/2023 11:24 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:SAVANNA ASSISTED LIVING LLCFACILITY NUMBER:
157209325
ADMINISTRATOR:ANGELES, REALIZAFACILITY TYPE:
740
ADDRESS:9013 STATEN ISLAND DRTELEPHONE:
(661) 889-6948
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 0DATE:
06/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Licensee Bongani “Peter” Mazibuko, Licensee Sarah Mazibuko and Administrator Realiza Angeles TIME COMPLETED:
11:35 AM
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On 06/06/23, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing / Component III Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry into the facility. LPA met with Licensee (L1) Bongani “Peter” Mazibuko and Licensee 2 (L2) Sarah Mazibuko. LPA toured facility with L! and L2. Administrator (A1) Realiza Angeles arrived shortly during tour.

The facility is a 3 bedroom and 2 bathroom home and fire clearance were granted for 5 Non-Ambulatory and 1 bedridden for a total capacity of 6. Facility temperature is observed set to 67 degrees F. Common areas were furnished and had adequate seating and lighting available. A fire extinguisher was observed and has a service date of 03/07/23. Medications will be kept lock in hall closet and inaccessible to residents in care. First aid kit was observed and contained all required items. Kitchen was toured and observed to have dishes, plate, and utensils. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. Knives were observed to be locked and secure in kitchen drawer. LPA observed an extra supply of bed linens and personal hygiene products. Cleaning supplies and chemicals were observed to be in a locked cabinet in the garage and under kitchen sink. All Bedrooms were observed to have required furnishings with adequately lightening. Bathroom observed with nonskid mat and grab bars. Hot water temperature 114.4 to in bathroom 1 and ranged between 119.4 degrees F to 119.2 degrees F in bathroom in the shared bedroom. Outside of facility toured. LPA observed adequate seating available for residents. Exits were open and free of obstructions. LPA observed side gate to be self-closing and self-latching. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. Facility phone number: 661-501-1439.

Component III was conducted during today's pre-licensing visit.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB
in Sacramento for final review prior to license being issued.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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