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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208775
Report Date: 09/26/2022
Date Signed: 10/04/2022 08:50:25 AM

Document Has Been Signed on 10/04/2022 08:50 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:MI CASITA CARE HOME IIIFACILITY NUMBER:
107208775
ADMINISTRATOR:JAIME, JUDITFACILITY TYPE:
735
ADDRESS:233 W NORWICH AVETELEPHONE:
(559) 349-2951
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 4CENSUS: 4DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Administrator, Judit JaimeTIME COMPLETED:
01:27 PM
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On 09/26//22, Licensing Program Analyst (LPA) M. Garza arrived at the facility unannounced to conduct an Infection Control/Annual Inspection. LPA contacted Licensee who arrived at the facility a short time later. LPA was greeted by Licensee, Judit Jaime. LPA stated the purpose of the visit and was allowed entry into the facility. LPA had temperature taken but was not screened with COVID control questions upon entry. LPA entered through a central entry point and observed a screening sign-sheet and PPE precautionary measures in place.

Licensee and Administrator, Carmen Muros toured facility inside and out with LPA. Clients were at program during visit. Infection control postings were observed. Furniture in common areas are spaced to promote physical distancing. A supply of PPE is located in the hallway closet. Hand washing postings were observed at hand washing stations.

Fire Extinguisher last serviced 1/20/2022. Water temperature measured at 108 degrees F in restroom #1 and 110 degrees F in the kitchen. LPA observed a first aid kit with all the required items. LPA requested the following updated forms by 9/30/22: LIC 308, LIC 309, LIC 500, LIC 610D, and LIC 9020.

No deficiencies cited during todays visit. Exit interview completed with Licensee and Administrator. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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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