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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208240
Report Date: 12/15/2023
Date Signed: 12/15/2023 11:12:12 AM

Document Has Been Signed on 12/15/2023 11:12 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
FRESNO RO, 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: 6DATE:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Senorita UtiTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Miriam Flores arrived unannounced to conduct the Annual inspection. LPA was granted entry by House Manager, Sherry Ross and explain the purpose of the visit. Licensee, Brad Kendall was present during this visit for a few minutes and left. Facility was toured with House Manager, Sherry Ross and Administrator, Senorita Uti.

During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed required food supply and paper products. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. First aid kit was checked and contained all required items.

Smoke detectors and carbon monoxide were checked and operating. Fire extinguisher was charged and was serviced on 03/11/2023. Emergency disaster drills are conducted quarterly, last drill completed on 12/01/2023. First Aid kit is fully equipped.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.



An exit interview was conducted, and a Plan of Correction was developed with Administrator, Senorita Uti. A copy of this report and Appeal Rights were discussed and left with Administrator whose signature on this form confirms receipt of these documents.

LPA requested the following updated forms faxed to CCLD by 12/29/2023: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Miriam Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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Document Has Been Signed on 12/15/2023 11:12 AM - It Cannot Be Edited


Created By: Miriam Flores On 12/15/2023 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: LYNN HOME
FACILITY NUMBER: 107208240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 6 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2024
Plan of Correction
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Licensee will submit pictures of the work completed to the backyard and replacement of the window blinds to the Department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
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