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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 277209277
Report Date: 11/07/2022
Date Signed: 11/16/2022 03:28:52 PM

Document Has Been Signed on 11/16/2022 03:28 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:ST. CHARLES GUEST HOMEFACILITY NUMBER:
277209277
ADMINISTRATOR:LAPITAN, JANETTEFACILITY TYPE:
740
ADDRESS:707 ST. CHARLES WAYTELEPHONE:
(831) 758-5145
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY: 6CENSUS: 4DATE:
11/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Licensee, Bernardino SunglaoTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA arrived and was granted entry to the facility by Licensee Bernardino Sunglao . An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 08/30/2022 for a capacity of six adult residents.

LPA Hurt observed the following:
Structure:
Facility is a one-story house with 6 resident bedrooms, 2 bathrooms, family / living room, dining area and kitchen. There is a 2-car garage attached in front of home. The resident bedrooms will accommodate residents' furnishings.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
Bedrooms #1-6 will accommodate 4 clients (each have their own bedroom)
Bathrooms:
All bathrooms have a working toilet, wash basin, and shower.
Linens and Hygiene Supplies:
Adequate supply of linens is stored in garage cabinet.
Emergency Phone Numbers, Exit Plan, and Sample Menu:
Will be posted and readily available for review in the living room.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ST. CHARLES GUEST HOME
FACILITY NUMBER: 277209277
VISIT DATE: 11/07/2022
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Continued from 809C...

Food Service:


Adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen and pantry.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems were hardwired and found operational.
Fire Extinguisher:
1 Fully charged and stored by front entrance near kitchen
Fire Clearance:
Approved on 10/27/2022
Appliances:
Electric four burner stove with oven, refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer are located in the laundry room in the hallways and were clean and noted to be operational.
Toxins:
Will be locked away/ stored in the garage area .
Water Temperature:
Tested and recorded at 110 degrees (within regulation)
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored in locked cabinet next to dining area. Medication will be stored and locked in cabinet next to dining area
Resident and Staff Files:
Records will be kept in filing area in living area.
Reading Material, Games, Equipment, & Materials:
The facility has materials that commensurate with their plan of operation.

Continued onto 809C..
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ST. CHARLES GUEST HOME
FACILITY NUMBER: 277209277
VISIT DATE: 11/07/2022
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Continued from 809C ..

The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Unit.

Applicant was reminded of the statute that requires notification to Licensing Program Analyst within 5 business days of admitting the first resident. This notification may be done by phone, mail, email or fax.

At this time, facility has met all pre - licensing requirements of Title 22 division 6.

An exit interview was conducted with Licensee Licensee, Bernardino Sunglao and a copy of this report was provided at the time of visit.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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