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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206629
Report Date: 04/07/2022
Date Signed: 04/07/2022 06:36:43 PM


Document Has Been Signed on 04/07/2022 06:36 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:ELIM PLACEFACILITY NUMBER:
107206629
ADMINISTRATOR:WOLF, RACHEL E.FACILITY TYPE:
740
ADDRESS:1808 5TH STREETTELEPHONE:
(559) 875-7268
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY:44CENSUS: 28DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Assistant Administrator (AA) Maria Ceballos; TIME COMPLETED:
06:45 PM
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An Annual Inspection Control visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Assistant Administrator (AA) Maria Ceballos.

One central entry point has been designated for universal entry screening. Routine symptom screening including temperature taken & recorded daily for all staff, residents, & visitors. Infection Control signs are posted. Soap & paper towels available. Hand sanitizer available for use. Face coverings in use & available. Sufficient supply of PPEs. Infection control policies & procedures & practices in place & currently applied.

No deficiencies issued.
Exit interview conducted with AA. Report Provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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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