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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204196
Report Date: 09/22/2022
Date Signed: 09/22/2022 11:08:17 AM


Document Has Been Signed on 09/22/2022 11:08 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:
09/22/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:44 AM
MET WITH:Administrator, Tynetta ShabazzTIME COMPLETED:
11:22 AM
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On 09/22/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management - annual continuation. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Administrator, Tynetta Shabazz.

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. LPA checked food supply, observed an adequate supply of food. 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 required furnishings.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/06/2022: 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.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Tynetta Shabazz, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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