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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208901
Report Date: 02/18/2022
Date Signed: 02/18/2022 10:42:52 AM

Document Has Been Signed on 02/18/2022 10:42 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:KAREN'S HOUSEFACILITY NUMBER:
107208901
ADMINISTRATOR:JACOBS, TEMIKA TRINAFACILITY TYPE:
735
ADDRESS:4744 W MENLO AVETELEPHONE:
(559) 275-3277
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 4CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Temika "Kym" JacobsTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Administrator (AD) Temika “Kym” Jacobs. LPA entered through the central entry point where health screening was conducted. Staff & Visitor sign in and screening process was observed.

Infection control procedures which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, residents and visitors), testing, visitation requirements, quarantine/isolation procedures, staffing, PPE and daily infection control procedures and vaccination requirements. All 4 residents are fully vaccinated.

LPA toured the facility inside and out. Required postings as well as Covid-19 and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available and clients have private rooms. LPA observed 30-day resident medication and PPE supply. Bathroom sinks are stocked with liquid soap, hand washing signs observed.


No deficiencies cited during today’s visit.


LPA requested the following updated forms by Friday 2/25/22: LIC309, LIC308, LIC 400 (if applicable), LIC402, LIC 500, LIC9020, Copy of current Liability Coverage
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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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