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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208244
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:55:10 PM

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:MY CARE HOMEFACILITY NUMBER:
107208244
ADMINISTRATOR:PONDOC, GLENDAFACILITY TYPE:
740
ADDRESS:5618 N TRACY AVETELEPHONE:
(559) 305-1682
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 2DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Teresita CreeTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with facility Designee Teresita Cree. LPA entered through the central entry point where hand sanitizer and screening was conducted. Administrator Glenda Pondoc joined shortly after arrival.

Infection control procedures which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, residents and visitors), testing, visitation, quarantine/isolation procedures, staffing, PPE and daily infection control procedures.

LPA toured the facility inside and out. Required postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Facility has multiple visitation areas available and both residents have a private room. LPA observed 30-day resident medication as well as PPE supply. Common and resident bathroom sinks are well stocked with liquid soap and paper towels for hand washing.

The following to be updated and submitted to LPA: LIC 308, 309 610E, LIC 500, LIC 9020, and proof of current Liability Insurance and Administrators Certificate to be submitted to CCLD on or before 11/9/2021


No deficiencies cited
A copy of this report and an exit interview was conducted with Administrator.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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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