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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206911
Report Date: 07/12/2022
Date Signed: 07/12/2022 02:43:25 PM

Document Has Been Signed on 07/12/2022 02:43 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:CAROLINA HOMEFACILITY NUMBER:
107206911
ADMINISTRATOR:DAMON HILLFACILITY TYPE:
735
ADDRESS:1086 CAROLINA AVENUETELEPHONE:
(559) 326-7758
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 4CENSUS: 4DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Misty Bryson, Program DirectorTIME COMPLETED:
03:00 PM
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On 7/12/22, 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 requested to meet with Administrator. LPA met with Kim Pendergraft, Direct support professional (DSP). Area Director Katherine “Katie” Chatton was called and authorized program director Misty Bryson to received report and conduct tour. LPA conduct tour with program director. There are currently four clients present during tour.

Upon entry facility staffs was observed with facial mask. Visitor log-in/temperature check was observed upon entry. 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. Social distancing and cough etiquette postings not observed in facility.

LPA checked clients’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. Cleaning supplies stored under kitchen sink.

All clients’ room toured and observed to be adequately furnished and lit. LPA observed four single occupant bedrooms. LPA observed trash bin with lid in one out of two bathrooms. Hand washing posting not observed by sinks.

The exterior tour was conducted. Outside free of obstruction. All clients’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 7/18/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610D, Lic 9020, and current Administrator certificate.

A copy of this report was provided to program director.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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