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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204196
Report Date: 10/19/2021
Date Signed: 10/19/2021 11:17:04 AM

Document Has Been Signed on 10/19/2021 11:17 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:HOME OF HOPE IFACILITY NUMBER:
107204196
ADMINISTRATOR:SHABAZZ, TYNETTAFACILITY TYPE:
735
ADDRESS:8623 N. PAULA AVETELEPHONE:
(559) 325-6305
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 6CENSUS: 0DATE:
10/19/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Licensee, Tynetta ShabazzTIME COMPLETED:
11:20 AM
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On 10/19/2021, Licensing Program Analyst (LPA) arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, disclosed the purpose of the visit and met with Licensee, Tynetta Shabazz. Facility has one central entry and exit point.

There are currently no residents residing in the facility and the facility is not staffed.

Facility tour conducted with Licensee. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. Hand-sanitizer is readily available. LPA checked food supply, observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Facility has an adequate supply of cleaning supplies. Facility has a sufficient amount of PPE supplies. Bathrooms are stocked with liquid soap and paper towels. Bedrooms toured. LPA observed the beds to be at least six feet apart and 3 feet apart with head to toe orientation.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/02/2021: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610-D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

No deficiencies issued.

An exit interview was conducted with Licensee. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site by Facility Representative.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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