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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201578
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:35:14 PM


Document Has Been Signed on 08/19/2022 03:35 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:WILLIAMS WHITTLE RESIDENTIAL CARE HOME #3FACILITY NUMBER:
107201578
ADMINISTRATOR:WHITTLE, CHERYL AFACILITY TYPE:
740
ADDRESS:4093 W. TERRACE AVENUETELEPHONE:
(559) 271-2152
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 3DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Lucille WilliamsTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Infection Control Inspection. LPA met with and explained the purpose of the visit with Lucille Williams.

LPA toured the facility inside and out. Infection control procedures which were observed and/or reviewed by LPA include: Daily symptom screenings for staff and program participants, testing & vaccination requirements, Isolation room procedures, social distancing, PPE and daily infection control procedures. Sanitizer is available throughout the facility. LPA observed 30-day supply of PPE, medications, paper goods and disinfecting products which were available for use.

There were no citations issued during this inspection.










LPA requested the following updated forms be submitted to CCL by 8/31/22: LIC 308, LIC 309, LIC 500, LIC 610E, LIC9020, current Liability Insurance and Administrator’s Certificate.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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