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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208868
Report Date: 03/07/2024
Date Signed: 03/07/2024 05:07:57 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/07/2024 05:07 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:MATHERSHED'S LOVING HANDS HOMEFACILITY NUMBER:
107208868
ADMINISTRATOR:MATHERSHED, TERRIFACILITY TYPE:
735
ADDRESS:4676 E KAVILAND AVETELEPHONE:
(559) 442-3723
CITY:FRESNOSTATE: CAZIP CODE:
93725
CAPACITY: 3CENSUS: 3DATE:
03/07/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Assistant Administrator (AA) Mao Mathershed TIME COMPLETED:
05:30 PM
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This visit is the initial Annual visit - not a continuation Case Management. Visit 2/2/4 recorded in error.
An Annual visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. McClurg. LPA met with Assistant Administrator (AA) Mao Mathershed. LPA introduced self, stated purpose of visit & was allowed entry.

Facility toured. Sufficient furnishings & lighting in front sitting room, dining room & living room. Fireplace in living room observed to be wood burning only with no gas or electrical, thereby removing reasonable & predictable harm as a source of heat. Fireplace has closing glass doors. Kitchen toured. Knives locked. Cabinets under kitchen sink observed to be locked making cleaners, etc. inaccessible. Sufficient amount of food on the premises. Food calculation process reviewed @ time of visit. Sufficient supply of service ware & utensils observed.

Resident rooms toured. Sufficient furnishings & adequate lighting. Resident bathrooms toured. Fixtures functional. Hot water tested & measured @ 105 Degrees F. Medications observed to be centrally stored in locked cabinet. Facility passageways observed to be clear & free of obstructions. 1st aid kit complete. Smoke & carbon monoxide detectors tested & observed to be operational. Fire extinguisher service date: 2/2/2024.

Outside area toured. Sufficient seating available. Yard maintained. Fences in good repair.

Visit to be continued at a later date.

Exit interview conduced with AA. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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