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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202834
Report Date: 05/28/2024
Date Signed: 05/28/2024 11:36:49 AM

Document Has Been Signed on 05/28/2024 11:36 AM - 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:NO PLACE LIKE HOMEFACILITY NUMBER:
107202834
ADMINISTRATOR/
DIRECTOR:		WARD, CAMISHA NICOLEFACILITY TYPE:
735
ADDRESS:6302 W LOS ALTOS AVETELEPHONE:
(559) 412-7290
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 3CENSUS: 2DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:23 AM
MET WITH:Chynell HarrisTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with facility designee (S1), Chynell Harris. Administrator Certification was confirmed during the visit. Census: 2 Residents were not present during the visit.

During this visit, LPA toured the facility inside & out Resident rooms are found to be in good repair and contained required furnishings and lighting. The resident bathroom was clean and in good repair with faucets delivering hot water at 116 degrees, grab bars and non-skid mats were in place. LPA observed required hygiene items, towels, extra bedding, and linens were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage as well as Emergency Preparedness supplies. Cleaning/disinfecting supplies, knives and sharps are locked and stored separate from food. Medications are locked and centrally stored in the kitchen cabinet. The First aid kits contained required items. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were serviced . Smoke and Carbon Monoxide detectors were tested and found to be in working condition. LPA conducted staff and resident file reviews including P&I logs. Emergency Disaster Plan and Infection Control Plans were reviewed during this visit and found to be updated.

There were no citations during this inspection. An exit interview was conducted, and a copy of this report was provided to S1, whose signature confirms receipt.


LPA requested the following updated forms faxed to CCLD by 5/20/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan (LIC610E (2019), Client Roster (LIC 9020), Proof of current Liability Coverage.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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