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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206911
Report Date: 10/17/2022
Date Signed: 10/17/2022 01:52:51 PM

Document Has Been Signed on 10/17/2022 01:52 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:
10/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Area Director Katherine Chattom and Program Director Misty BrysonTIME COMPLETED:
01:48 PM
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On 10/17/22, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced complaint investigation and met with Misty Bryson, Program Director (PD). Area Director, Katherine Chattom arrived shortly.

During the course of the investigation, LPA reviewed records and observed on facility record, on 09/18/22 at 04:00 PM staff did not administer Client 1 (C1) medication: Gabapentin. LPA interviewed with PD who confirmed staff audit medication and medication was administered to C1 at 04:00PM.

No deficiencies issued.

Exit interview was conducted. A copy of this report was provided to Area Director.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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