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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208240
Report Date: 03/16/2022
Date Signed: 03/17/2022 10:11:25 AM

Document Has Been Signed on 03/17/2022 10:11 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:LYNN HOMEFACILITY NUMBER:
107208240
ADMINISTRATOR:TATUM, ATLENAFACILITY TYPE:
735
ADDRESS:2715 HELM AVETELEPHONE:
(559) 348-9946
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 5DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Donna Taylor - Administrator TIME COMPLETED:
03:45 PM
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Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a Required Annual inspection. LPA met with Co-Administrator Donna Taylor. Administrator certificate is current with renewal date 6/17/2023.

LPA toured the facility inside and out. All passageways and exits were clear and free from obstruction. The facility was at a comfortable temperature. All smoke detectors and carbon monoxide detectors were operational. The outdoor space had enough seating for residents in a covered area. The fence had a closing gate with a secure latch. LPA observed a two day supply of perishables and a seven day supply of nonperishable food stuffs. Medications were kept in a locked closet in the living area, and medications appeared to be administered properly. Chemicals and cleaning supplies were kept in a locked cabinet in the laundry room. Facility had sufficient hygiene items and linen supply for residents. LPA toured all resident bedrooms and bathrooms. LPA observed that resident bedrooms did not have chairs available for residents. LPA issued LIC 9102 Technical Violation and discussed minimum required furnishings with Administrator.

LPA reviewed Infection Control protocols and best practices and facility Emergency Disaster Plan with Administrator. Administrator agreed to provide LPA with updated LIC 500, LIC 9020, LIC 400, and LIC 610D. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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