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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200867
Report Date: 09/24/2024
Date Signed: 09/24/2024 04:31:37 PM

Document Has Been Signed on 09/24/2024 04:31 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:SHEPHERD'S INNFACILITY NUMBER:
275200867
ADMINISTRATOR/
DIRECTOR:		WILLIAMS, LITA P.FACILITY TYPE:
740
ADDRESS:11899 CYPRESS CIRCLETELEPHONE:
(831) 632-2200
CITY:CASTROVILLESTATE: CAZIP CODE:
95012
CAPACITY: 6CENSUS: 4DATE:
09/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:25 PM
MET WITH:Licensee Lita WilliamsTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 9/24/2024 Licensing Program Analysts (LPAs) B. Miranda & R. Bruce arrived at the facility unannounced to check on the POCs. LPAs introduced themselves and explained the reason for the visit. LPAs met with Licensee Lita Williams.

LPAs observed the following and cleared POCs:
On 7/27/2024 Licensee bought smoke detectors and installed them at the facility, POC cleared
Garage was cleaned and reorganized, POC cleared
Cleaning solutions and locked under the sink, POC cleared
Food storage area in the garage has been cleaned, POC cleared
Kitchen area in the garage has been cleaned and reorganized, POC cleared
Food containers in garage have been replaced, POC cleared
Centrally Stored Medication Log has been corrected and updated, POC cleared
Staff are cleared and allowed to return to the facility, POC cleared

POCs were cleared, printed, and provided to the Licensee.

Exit interview was conducted and a copy of this report LIC809 was provided to Licensee.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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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