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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208249
Report Date: 10/17/2024
Date Signed: 10/17/2024 05:13:08 PM


Document Has Been Signed on 10/17/2024 05:13 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:GRACE HOME KAREFACILITY NUMBER:
107208249
ADMINISTRATOR:YANG, YUEPINGFACILITY TYPE:
740
ADDRESS:3232 EVERGLADE AVETELEPHONE:
(559) 765-9849
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 6DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator - Yueping YangTIME COMPLETED:
05:15 PM
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On 10/17/2024, Licensing Program Analyst (LPA) M Vega arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured facility with an Administrator (AD) Yueping Yang (Aimee) was notified of Licensing visit over the phone and was able to attend the visit. AD certification number 6044266740 and expiration date 05/17/2025.

Facility has one entrance point. LPA toured facility with Administrator inside and out. An outdoor seating area was observed for residents in care. LPA observed every resident's room equipped with emergency exits in case of disaster.

The facility was observed to be at a comfortable temperature, of 75 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed some residents in common area after breakfast, others in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility.

Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

Fire extinguisher was observed with a service date of 5/3/24. All 6 residents’ bedrooms were observed to be with comfortable temperature.

Report continues on LIC809-C
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GRACE HOME KARE
FACILITY NUMBER: 107208249
VISIT DATE: 10/17/2024
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Medications observed to be locked in a cabinet in hallway area next to kitchen. LPA reviewed medication records, records maintained no deficiencies observed at this time.

Cleaning supplies were observed to be in a locked cabinet in the laundry room.

LPA reviewed Staff and Resident files. Resident files observed to have updated information.

No deficiencies were observed and cited. Exit interview conducted.
Report was signed and copy of this report was provided for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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