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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204055
Report Date: 10/23/2024
Date Signed: 10/23/2024 11:11:04 AM

Document Has Been Signed on 10/23/2024 11:11 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SENGSIRI HOMEFACILITY NUMBER:
107204055
ADMINISTRATOR/
DIRECTOR:
SENGSIRI, BRIGIDAFACILITY TYPE:
735
ADDRESS:1142 CARSON AVENUETELEPHONE:
(559) 325-1752
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator: Brigida SengsiriTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 10/23/24 at 8:30 am Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greeedt by Brigida Sengsiri, Licensee (L1). LPA was granted entry. 1 client was present upon arrival and was waiting for Day Program pickup. The other 5 residents had previously departed for Day Program.

LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good condition,, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. A sample of resident’s medications were checked and observed kept locked in medication cart. Clients’ MARS was reviewed. Cleaning chemicals was observed stored and locked in facility. Fire extinguisher was observed with a service date of: 11/5/23. Fire drill last completed on 7/1/24. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested 110 degrees F in bathroom 1, 110 degrees F in bathroom 2 and 110 degrees F in bathroom 3.

Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature was maintained range at 0 degrees F and refrigerator temperature was maintained range at 41 degrees F. Carbon monoxide and smoke detector were tested and observed to be operational. All clients’ files reviewed to have all the required documents. Samples of staff files were reviewed to have all required documents.

No deficiencies issued during this inspection.

Continued on LIC-809C

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SENGSIRI HOME
FACILITY NUMBER: 107204055
VISIT DATE: 10/23/2024
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Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 11/6/24: Lic 308, Lic 400, Lic 402, Lic 500, and Lic 610D. A copy of this report was provided to Brigida Sengsiri L1, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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