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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208859
Report Date: 05/25/2022
Date Signed: 05/25/2022 06:28:28 PM

Document Has Been Signed on 05/25/2022 06:28 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CORPUZ ADULT RESIDENTIAL FACILITY INCFACILITY NUMBER:
107208859
ADMINISTRATOR:CORPUZ, JIMENAFACILITY TYPE:
735
ADDRESS:1536 BARSTOW AVENUETELEPHONE:
(559) 472-3470
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:21 PM
MET WITH:Licensee Jimena Corpuz. TIME COMPLETED:
06:45 PM
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On 05/25/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Licensee Jimena Corpuz. LPA conducted a facility tour with Licensee Jimena Corpuz. All six clients present during tour.

Upon entry facility staffs was observed with facial mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility.

LPA checked clients’ locked medications. Food supply was checked and appeared to be an adequate supply. All clients’ room toured and observed to be adequately furnished and lit. LPA observed three shared clients’ bed to be at least 6 feet apart. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. Cleaning supplies were stored and locked in cabinet in the laundry room.

The exterior tour was conducted. Outside free of obstruction and debris. LPA observed a 30-day PPE supplies. LPA observed fire extinguisher served date: 06/08/21. Staff records were reviewed for good health and infection control training. All clients’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 05/31/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 610D, Lic 808, Lic 9020, and control of property. LPA received copy of Administrator Certificate and Lic 500 during inspection.

Administrator was provided a copy of this report.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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