<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202381
Report Date: 08/24/2021
Date Signed: 08/25/2021 10:05:17 AM

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:GIFT OF GRACE CARE HOMEFACILITY NUMBER:
107202381
ADMINISTRATOR:PAMELA LEWISFACILITY TYPE:
740
ADDRESS:1480 W. SAN MADELE AVENUETELEPHONE:
(559) 284-8857
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Phoeun Marez - Co-Administrator TIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this date, Licensing Program Analysts(LPA's) D. Ayers and M. Yang arrived at the facility unannounced to conduct a Required Annual Inspection. LPA's met with Co-Administrator Phoeun Marez. Administrator certificate was current with renewal date 6/13/2022.

LPA's toured facility inside and out. All passageways and exits were clear and free from obstruction. Fire extinguisher had current service tag dates. Facility had smoke detectors in hallways and bedrooms which were operational. Carbon monoxide detector was operational. Facility was adequately furnished and lit. LPA's observed all hazardous materials and cleaning supplies to be secured in a locked storage room. Medications were kept in a locked cabinet in the laundry room, and medications appeared to be administered properly. LPA's observed a fourteen day supply of nonperishable food stuffs and a two day supply of perishable food stuffs which were stored properly.

LPA's toured resident bedrooms and bathrooms. Bedrooms were adequately furnished and lit. Bathrooms were clean, odor free, and had secure grab bars and nonskid mats in showers. No deficiencies cited during the inspection. Exit interview conducted. A copy of the report was provided to the licensee via email.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1