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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208825
Report Date: 12/26/2023
Date Signed: 12/26/2023 02:27:28 PM


Document Has Been Signed on 12/26/2023 02:27 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:FAMILY IS WHYFACILITY NUMBER:
107208825
ADMINISTRATOR:DEANGELA TEASLEYFACILITY TYPE:
740
ADDRESS:2495 S. RABETELEPHONE:
(334) 652-9491
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 3DATE:
12/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:DeAngela Santos, AdministratorTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) L. Padgett arrived unannounced to conduct the Annual inspection. LPA was granted entry to the facility by Staff (S1). S1 called Administrator DeAngela Santos (AD) who arrived shortly thereafter. LPA explained the purpose of the visit. Upon arrival LPA observed R1 and R2 participating in a craft activity at the dining table.
During this visit, LPA and AD toured the facility. Resident rooms contained required furnishings and lighting.
LPA observed required items in bathrooms with hot water measured at 106.4 degrees F. Resident hygiene
supplies were properly stored and available. LPA observed no non-skid mat or strips in the two bathrooms used by residents. AD ordered non-skid strips for store pick up while LPA was still at the facility. Since issue was addressed during visit LPA will not issue deficiency. The kitchen was toured observed in good repair with necessary items and appliances. Sharps/knives were properly stored in locked box in bottom kitchen cabinet. LPA observed required food supply and paper products. Medications are centrally stored and locked in hall closet. Doors and passageways are unobstructed throughout the facility including outdoors.
Facility First Aid kit observed and was found to contain required items. Sufficient supply of perishable and non-perishable food observed.
Fire Extinguisher located in the dining room was purchased on 12/21/2022. Garage is accessed from the side of the home and is maintained locked. In the garage LPA observed personal hygiene items, garden tools. Smoke/Carbon Monoxide (combo device) detector in the hallway was tested and found to be operational. LPA conducted resident and staff file reviews and staff interviews.

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/3/2024: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond a liability insurance, proof of control of property(lease or grant deed ).
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023
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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