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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209377
Report Date: 04/04/2024
Date Signed: 04/04/2024 12:07:48 PM

Document Has Been Signed on 04/04/2024 12:07 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:BURLINGTON, THEFACILITY NUMBER:
157209377
ADMINISTRATOR/
DIRECTOR:		GIBSON, KALAFACILITY TYPE:
740
ADDRESS:13 SYCAMORE DRTELEPHONE:
(415) 810-0145
CITY:WOFFORD HEIGHTSSTATE: CAZIP CODE:
93285
CAPACITY: 21CENSUS: 18DATE:
04/04/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Administrator Kala GibsonTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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On 04/04/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct case management visit for the purpose of checking on the health and safety of the residents in care. LPA introduced self, stated the purpose of the visit, and met with Administrator Kala Gibson.

During today's inspection, LPA conducted a tour of the facility. All passageways were clear from obstructions. Residents were observed in hallway, outside porch, and in bedrooms.

No deficiencies cited during today's inspection.

Exit interview conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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