107206785-4-11-2024-24-AS-LPAT-D48UKY-20240411153952

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206785
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:41:12 PM

Document Has Been Signed on 04/11/2024 03:41 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:	PETERSON RESIDENTIAL		FACILITY NUMBER:	107206785
ADMINISTRATOR:	O'DONNELL, CAROL		FACILITY TYPE:	740
ADDRESS:	455 S. KONA		TELEPHONE:	(559) 492-2189
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	6	CENSUS: 4	DATE:	04/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Carol O'Donnell, Licensee/Administrator		TIME COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with care giver Ruth Patzkowsky (RP) and explained the purpose of the visit. Facility was toured with RP. Administrator (AD) Carol O'Donnell arrived later. At the time of the visit, LPA observed 4 residents in the facility. LPA with AD toured the kitchen. LPA observed that the kitchen was well maintained, with working lights and well maintained appliances. The knives were kept in a locked drawer. The kitchen counters are cluttered however was clean. LPA observed two trash bins with the lid. LPA observed that refrigerator well maintained and clean. LPA observed a 2 day perishable food supply. The kitchen pantry was clean, organized, and had an emergency supply of 124 servings of non perishable food. No expired food was observed. LPA observed the dining room is well lit. The table and can seat 4 people. Laundry room is kept locked, LPA observed the storage cabinet to contain laundry detergents and cleaning products. Medications are stored in a separate section of this storage cabinet. First aid kit was observed and contained all required items. LPA observed that the garage. The door is kept locked and RP explained that residents do not have access to this room. Garage is contains many miscellaneous items as well as hygiene items for residents. LPA observed 4 cats and a cat tree and other cat items. The garage has one upright freezer, with mostly meats. LPA inspected the living room with RP. Fireplace was observed with glass cover, television was observed to be in a secure place, piano and empty bird cage. The living room floor was in good condition. LPA observed one sofa and 2 recliners. The living room has a sliding glass door that is kept clean and is not obstructed. The furniture was clean and in good condition.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PETERSON RESIDENTIAL	FACILITY NUMBER: 107206785
	VISIT DATE: 04/11/2024

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LPA observed the hallway that leads to the bedrooms and observed night lights. A fire extinguisher is mounted on the wall and inspected on 11/21/2023 with the pressure gauge in good range indicated on the meter. The smoke alarm and carbon monoxide detectors were tested by the RP and are functioning. LPA observed that the thermostat is within range of the regulation at 73 degrees F.

LPA inspected the hallway bathroom with RP and observed that the bathroom is well maintained, well lit, has paper towels, toilet paper, hand soap, a small trash bin with lid on the counter. Water temperature measured at 111.4 degrees F. The bathroom was observed to have non-skid mat, grab bars in shower, grip bars around toilet, and faucet. The toilet was flushed and is working. LPA observed the linen closet to have clean towels, linens.

LPA inspected resident’s bedrooms with RP. LPA observed Bedroom #1 is shared. LPA observed two beds, chair, TV, 2 dressers. Window operable with screen in good condition. The smoke detector was tested and found to be functioning. Bedroom 2 is shared. LPA observed two beds, 2 dressers, desk area, closet, window operable and screen in good condition. Smoke detector tested and found to be functioning.

LPA observed multipurpose room which contains exercise bike, elliptical and 4 cats a cat tree and two litter boxes.

LPA with AD inspected the backyard. LPA, observed that the backyard portioned off. Behind a locked gate is a koi pond and turtle pond. Patio table and bench is clean and ready for use. LPA observed large bird cage with 10-11 birds. LPA observed a section of the yard fenced off and locked. AD opened this gate and LPA observed miscellaneous items and a shed. On the other side of the yard is the side gate was self-closing and self-latching.

LPA conducted resident and staff file reviews. An exit interview was conducted. A copy of this report was discussed and left with AD whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 4/18/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), updated facility yard sketch, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), LIC 9052

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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