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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247208959
Report Date: 07/31/2023
Date Signed: 08/01/2023 02:00:01 PM

Document Has Been Signed on 08/01/2023 02:00 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:AT HAVEN HOMEFACILITY NUMBER:
247208959
ADMINISTRATOR:BURNS, JASMINFACILITY TYPE:
740
ADDRESS:644 DARTMOUTH COURTTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY: 6CENSUS: 5DATE:
07/31/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Juliana Ruiz - CaregiverTIME COMPLETED:
09:45 AM
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On 7/31/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Plan of Correction(POC) inspection. LPA contacted Administrator Jasmine Burns and announced the purpose of the inspection.

This visit was conducted as a follow-up to a Required Annual Inspection which was conducted on 7/20/2023. During the visit, LPA toured the facility and verified that corrections were made to deficiencies which were observed and cited on 7/20/2023. No deficiencies were cited during the inspection. A copy of the report was provided to the administrator and exit interview conducted.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
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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