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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206824
Report Date: 05/14/2024
Date Signed: 05/24/2024 02:12:24 PM

Document Has Been Signed on 05/24/2024 02:12 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:MI CASITA DOSFACILITY NUMBER:
107206824
ADMINISTRATOR/
DIRECTOR:		JUDIT JAIMEFACILITY TYPE:
735
ADDRESS:296 W. RICHERT AVENUETELEPHONE:
5592921316
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 4DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:14 AM
MET WITH:Judit Jaime, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst L. Padgett (LPA), conducted an unannounced annual visit to the facility and met with Manager, Maria “Carmen” Muros (MA). Licensee/Administrator (AD) Judit Jaime arrived shortly thereafter. LPA stated the purpose of the visit and was accompanied by MA while conducting the inspection of the facility. At the time of the visit, LPA observed 3 residents in the facility.

LPA observed that the kitchen was well maintained, with working lights and well maintained appliances. The knives were kept in a locked cabinet. The kitchen counters and sink are free from debris. LPA observed a trash bin with the lid. LPA observed that refrigerator, was kept at a 43.9 degree F. Refrigerator and the freezer are well maintained and clean. LPA observed a 2 day perishable food supply. The kitchen cabinets are clean, organized, and had 7 days of non-perishable food. No expired food was observed. A fire extinguisher is mounted on the wall and inspected on 1/2/2024 with the correct pressure gauge as indicated on the meter. Activity calendar is displayed. MA opened the medication cabinet for inspection. LPA observed medication cabinet contained the first aid kit and medication bins for each resident, labeled and organized. First aid kit was inspected and found to be in compliance per regulation to have tweezer, bandages, manual, scissors and wound ointments.

LPA observed that the garage is well maintained, free from obstructions and debris. LPA observed the locked storage cabinet to contain, laundry detergents and cleaning LPA observed washer and dryer in the garage. Emergency supply of drinking water observed.

LPA toured the living room with MA. No fireplace was observed, television was observed to be in a secure place. LPA observed a sofa and 3 comfortable chairs. The living room can accommodate at least 6 people. The living room has a French doors that lead to the back yard. It is kept clean and is not obstructed. The furniture was clean and in good condition.

LPA observed the dining room is well lit. Shelves contains games and art supplies. Dining table seats 12.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: MI CASITA DOS
FACILITY NUMBER: 107206824
VISIT DATE: 05/14/2024
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LPA observed the hallway that leads to the bedrooms and observed night light, The smoke alarm and carbon monoxide detectors were tested by the MA and are functioning. LPA observed that the room temperature is within range of the regulation at 73 degrees F.

LPA inspected the hallway bathroom with MA and observed that the bathroom is well maintained, well lit, has paper towels, toilet paper, hand soap, a trash bin with lid. Water temperature measured at 110.7 degrees F. The bathroom was observed to have non-skid mat, grab bars in the shower, and shower bench. The toilet was flushed and is in working condition. Nothing is kept under the sink.

LPA observed the linen closet to have clean linens, towels and toiletries container for each resident.

LPA observed that bedroom #1 is not shared and has no private bathroom. The bedroom is well lit and contains night stand beside the bed, a closet and dresser that is able to hold the resident's personal belongings. Furniture and linens are in good condition. Window is operable and the screen is in good condition.

LPA observed that bedroom #2 is a shared bedroom, with two twin beds and have enough space in between them. The room is well lit, a dresser for each resident, 2 chairs and a closet are shared and are able to hold both residents' personal belongings. Linens and furniture are free from stain and debris. Window is operable and the screen is in good condition.

LPA observed Bedroom #3 is not shared, has a private bathroom with covered trash bin, shelves for toiletries. AD flushed the toilet and it was found to be working properly. The water temperature measured at 108.9 degrees F. The bedroom is well lit. The furniture are in good condition, the linens are in good condition. The bedroom has a closet, dresser and night stand. Window is operable and the screen is in good condition.

LPA, observed that the backyard is well maintained, trees, bushes and grass in good condition. Patio furniture is clean and ready for use. The exterior walkways are free from obstructions and debris. Side gate has self latching device.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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: MI CASITA DOS
FACILITY NUMBER: 107206824
VISIT DATE: 05/14/2024
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LPA reviewed residents and staff records with AD and found that all documents are in order and up to date.
An exit interview was conducted with AD, Judit Jaime.

LPA is requesting the following documents be submitted to the Fresno CCL office by 5/24/2024. Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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