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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100407464
Report Date: 02/10/2025
Date Signed: 02/11/2025 02:22:11 PM

Document Has Been Signed on 02/11/2025 02:22 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DAILEY'S HAVENFACILITY NUMBER:
100407464
ADMINISTRATOR/
DIRECTOR:		MEDINA, MYSTIFACILITY TYPE:
735
ADDRESS:4479 N. EDDYTELEPHONE:
(559) 291-7759
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 6DATE:
02/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Estelle Dailey, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rachel Bruce arrived unannounced to conduct the Annual inspection. LPA was granted entrance by Direct Care Giver, Joe Garcia, who reached out to licensee Estellle Dailey who arrived shortly thereafter. LPA explained the purpose of the visit and Licensee conducted tour of facility both inside and outside.
Resident bedrooms were toured and observed to be clean and free of obstruction with adequate lighting. Windows are screened and operational. LPA observed required items in bathrooms with hot water measuring 104.7 and 109.7 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances. Sharps/knives were properly stored in locked cabinet in kitchen. LPA observed required food supply and paper products. Overflow of food is stored in second refrigerator in garage. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit located in the kitchen and contained required items.
Fire Extinguisher located in the kitchen was serviced in 2/4/2024. Smoke and Carbon Monoxide detectors were tested and found to be functioning. LPA conducted resident and staff file reviews. Required documentation was present, and Licensee will ensure that the Needs and Services Plans are appropriately updated. Administrator’s re-certification was confirmed to be in active status.
Backyard was free of obstruction, however the fencing is in need of repair. There is a non-functioning chain link fence located adjacent to the cinder block fence that replaced it. There is also a need to repair several slats of wood which are deteriorated. Citation issued on the attached Deficiency page.

LPA is requesting the following documents be submitted to the Fresno CCL office by 3/1/2025: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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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Document Has Been Signed on 02/11/2025 02:22 PM - It Cannot Be Edited


Created By: Rachel A Bruce On 02/10/2025 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DAILEY'S HAVEN
FACILITY NUMBER: 100407464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation/inspectoin, the licensee did not comply with the section cited above with a backyard fence in need of repair and chain link fence which needs to be removed. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2025
Plan of Correction
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Licensee stated the repairs will be made by the due date and pictures will be sent to document the changes are adequate.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Rachel A Bruce
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025


LIC809 (FAS) - (06/04)
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