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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206708
Report Date: 09/29/2023
Date Signed: 09/29/2023 12:55:19 PM


Document Has Been Signed on 09/29/2023 12:55 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 #8FACILITY NUMBER:
107206708
ADMINISTRATOR:KUTNERIAN, GEORGEFACILITY TYPE:
740
ADDRESS:6705 N. MAPLE AVETELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 5DATE:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Angela KutnerianTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by Assistant Administrator, Jaycee Sanderson (AD2); LPA stated the reason for this visit. This inspection was conducted with Administrator Angelica Kutnerian (AD1) and Jaycee Sanderson.

The residence was set at 76 F temperature and free of passageway obstructions inside and outside. LPAs observed six bedrooms in the residence. Four of the five bedroom are occupied by residents. Residents' rooms were toured and inspected. Sixth bedroom is used as an office by the administrator. Each bedroom room was found to be clean, and furnishing was in good condition. Hot water temperature was measured at 118 degrees F.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. Medication and knives are locked next to the laundry room. Smoke detectors and carbon monoxide are dual detectors, they were checked and operating. Fire extinguishers were charged and was serviced on 8/2/2023. Emergency disaster drills are conducted quarterly, last drill completed on 9/01/23. Staff and residents were interviewed.

There was outdoor seating for the residents. Outdoor area was clean and free of obstruction.

An exit interview was conducted, and a copy of this report was provided to AD1 whose signature confirms receipt.



LPA requested the following updated forms faxed to CCLD by 10/20/23: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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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