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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208813
Report Date: 09/27/2021
Date Signed: 09/27/2021 11:15:22 AM

Document Has Been Signed on 09/27/2021 11:15 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:MRS SCOTT'S WHERE HEART IS HOMES-CARMEL BY THE SEAFACILITY NUMBER:
107208813
ADMINISTRATOR:MAREZ, PHOEUNFACILITY TYPE:
740
ADDRESS:292 W TRENTON AVETELEPHONE:
(559) 298-7992
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 5DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Administrator, Phoeun MarezTIME COMPLETED:
11:12 AM
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Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator, Phoeun Marez and discussed the purpose of the visit.

LPA Williams toured the facility with staff.

LPA Williams observed a visitor/temperature log, masks, gloves, and disinfection station at the front entrance. Facility has one entry and exit point. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies and medications were observed behind a locked door. LPA Williams observed the following personal protective equipment in storage; gowns, face shield, gloves, and masks. LPA Williams observed all facility staff wearing masks.

Staff have received training regarding Covid-19 infection control and mitigation. 5 of 5 resident’s files had updated emergency contact information.

LPA Williams requested the following documents be sent to the Department by 10/6/2021; personnel report (LIC 500) ,designation of facility responsibility (LIC 308), administrator certificate, and mitigation plan (LIC 808).

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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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