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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206783
Report Date: 01/19/2023
Date Signed: 02/01/2023 09:19:08 AM

Document Has Been Signed on 02/01/2023 09:19 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:FOREVER CARE INC/ ALTA HOUSEFACILITY NUMBER:
107206783
ADMINISTRATOR:SMITH, BONNIEFACILITY TYPE:
735
ADDRESS:5829 E ALTATELEPHONE:
(559) 903-2661
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 4CENSUS: 3DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Bonnie Smith, LicenseeTIME COMPLETED:
09:15 AM
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On 01/19/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Licensee Bonnie Smith. LPA toured facility with Administrator. All three clients were present during the inspection.

Visitor log-in/temperature check was observed upon entry. LPA observed staffs with face covering. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed COVID-19 related signs and cough etiquette posting in facility.

LPA observed fire extinguisher served date: 11/18/22. Food supply was checked and appeared to be an adequate supply. All client’s room toured and observed to be adequately furnished and lit. LPA observed 3 bedrooms that are single occupant. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. LPA checked clients’ locked medications and observed a 30-day PPE supplies. Cleaning supplies were stored and locked in hall closet and utility room.

The exterior tour was conducted. Side gate was self-closing and free of debris. LPA observed all clients’ records reviewed to have updated emergency contact information. Staff records were reviewed for good health and infection control training.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 01/31/23. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 500, Lic 610D, and Lic 9282. A copy of this report was provided to Licensee.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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