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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208775
Report Date: 08/29/2024
Date Signed: 09/06/2024 01:10:46 PM

Document Has Been Signed on 09/06/2024 01:10 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:MI CASITA CARE HOME IIIFACILITY NUMBER:
107208775
ADMINISTRATOR/
DIRECTOR:
JAIME, JUDITFACILITY TYPE:
735
ADDRESS:233 W NORWICH AVETELEPHONE:
(559) 349-2951
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 4CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Judit JaimeTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Daiquiri Boyd arrived unannounced to conduct an annual visit. LPA introduced self, stated the purpose of the visit and was greeted by Administrator Maria Muros, who called Licensee, Judith Jaime, who then came to assist LPA. LPA toured facility with Licensee and Administrator, Maria Muros. Upon arrival, three clients were waiting for the transport bus to take them to their Program.

The tour started in the kitchen into the common areas, to the client's bedrooms, and bathrooms. The facility was observed to be at a comfortable temperature of degrees 74 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. Cleaning supplies and chemicals stored and locked in the garage. Medications observed kept locked in the kitchen area. All bedrooms were observed to have required furnishings and with adequate lightening. LPA observed four single occupant rooms. Bathrooms were properly equipped, and the hot water temperature was tested at 108 degrees F. Fire extinguisher was observed with a service date of 08/01/2024. Fire drill last completed on 08/01/24. Outside of facility toured and observed to be free of debris. Carbon monoxide and smoke detectors were tested and observed to be operational. Staff and client’s files were reviewed. First Aid checked and fully stocked.

No deficiencies issued during this inspection. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by Administrator. Forms requested: LIC308, LIC 309, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9282, and control of property will be submitted by 9/12/24. A copy of this report was provided to the Licensee, whose signature on this form confirms receipt of this report
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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