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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202381
Report Date: 08/24/2022
Date Signed: 08/24/2022 01:03:56 PM


Document Has Been Signed on 08/24/2022 01:03 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: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:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Phoeun Marez TIME COMPLETED:
01:09 PM
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On 8/24/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self and allowed entrance by Direct Care Staff. All COVID-19 screening precautions are in place. Sign in book, hand sanitizer, COVID-19 screening paperwork observed at entry point. All staff and visitors enter through front door. Direct Care staff contacted Co-Administrator, Phoeun Marez who arrived a short time later to conduct inspection. Phoeun Marez, Administrator Certificate #6031818740, expires 6/13/2024.

Facility appeared clean with no obstruction or fire clearances issues. Social distancing is maintained in the common area and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Resident bedrooms toured, there are 2 shared rooms and one private bedroom, bedrooms that are shared have a minimum of 6 feet between beds.

LPA checked residents’ medications and observed a 30-day supply. LPA observed a 2-day of perishable and a 7-day of non-perishable food available. All resident rooms are private. Bathrooms toured, grab bars and non-skid mats observed. Medication observed to be locked and secured. All residents have a 30-day supply of medication available. Fire extinguisher present and has a service date of 7/25/22. Last Fire Drill conducted 7/11/22 per facility records.

Outside toured. Exit observed to be free obstruction. Pool is locked and secured and inaccessible to residents. Back storage shed observed to be locked.

Licensee to submit the following documents to Fresno CCL office no later than 09/02/22: Copy of Administrator Certificate, First Aid card, LIC 500, LIC 610, and LIC 9020.

No deficiencies were observed. Exit interview was conducted. A copy of report provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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