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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100405566
Report Date: 02/22/2024
Date Signed: 02/22/2024 02:46:44 PM


Document Has Been Signed on 02/22/2024 02:46 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:PRINCE & PRINCESS HOME FOR THE ELDERLYFACILITY NUMBER:
100405566
ADMINISTRATOR:PRINCE, BETTYFACILITY TYPE:
740
ADDRESS:4686 E. CORTLANDTELEPHONE:
(559) 231-5728
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:6CENSUS: 3DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee/Administrator (L/A) Betty Prince & Caregiver John Prince (husband to L/A)TIME COMPLETED:
03:00 PM
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An Annual visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Licensee/Administrator (L/A) Betty Prince & Caregiver John Prince.

Physical plant toured. Dining & Living rooms furnished sufficiently with adequate lighting. Resident bedrooms sufficiently furnished with adequate lighting. Resident bathroom toured. Grab bars in toilet & shower areas. Interior & exterior passageways clear & free of obstructions. Kitchen has sufficient service ware & utensils. Sufficiently supply of food on the premises. Facility appeared to be clean with no unpleasant odors. Resident appeared to be in good spirits, clean, & well groomed. Lunch served during visit appeared to be healthful, with appropriate serving sizes. Residents were given a choice of lunch & appeared to enjoy the meal.

Medications centrally stored & observed to be locked. Hazardous items, cleansers, etc., observed to be locked & inaccessible to residents. Smoke detectors tested & observed to be operational. Fire extinguisher service date: 7/10/2023. Side yard area with motor-home & additional storage observed to be properly fenced with lock gate. This property has an in-ground pool. Pool area appropriately fenced with locked gate.

Annual to be continued @ a later date.
Miscellaneous subjects & items discussed including CARE tool.

Exit interview conducted with L/A. Report provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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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