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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204175
Report Date: 08/15/2024
Date Signed: 08/15/2024 08:25:41 PM


Document Has Been Signed on 08/15/2024 08:25 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:FRESNO GUEST HOME #4FACILITY NUMBER:
107204175
ADMINISTRATOR:KUTNERIAN, ANGELICAFACILITY TYPE:
740
ADDRESS:6817 N. ROWELLTELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 6DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teresa LongTIME COMPLETED:
12:15 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
Licensing Program Analysts (LPA) Daiquiri Boyd arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Teresa Long.

During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting. The bathrooms were found to be clean with faucets delivering hot water at 117.7 degrees. LPA observed required hygiene items, towels, extra bedding, and linens which were stored and available for use. The kitchen was clean, with necessary items and appliances, all sharp objects were in a locked cabinet. LPAs observed required food supply and paper product storage. Medications are locked and centrally stored in a locked kitchen pantry closet. Common and activity areas were clean and occupied by residents throughout. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The fire extinguisher was serviced August 5th, 2024. Temperature in the home was 75 degrees. Smoke/carbon monoxide detectors were seen throughout the home and smoke alarm was tested and working.

LPAs reviewed three resident files and three staff files. All files had required documents.

LPAs requested Licensee to submit the following documents: LIC308, LIC309, LIC500, Proof of Liability Insurance, and facility sketch by August 22nd, 2024.

No deficiencies were cited on this day. LPAs conducted an exit interview with Administrator.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Daiquiri BoydTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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