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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209014
Report Date: 12/04/2023
Date Signed: 12/04/2023 02:20:22 PM


Document Has Been Signed on 12/04/2023 02:20 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:MCWEALTH CARE INC. WATHEN HOMEFACILITY NUMBER:
107209014
ADMINISTRATOR:GAYLORD, APRILFACILITY TYPE:
735
ADDRESS:5943 W WATHEN AVENUETELEPHONE:
(559) 458-3947
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:4CENSUS: 3DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:April GaylordTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) April Gaylord.

During this visit, LPA toured the facility inside & out. Resident bedrooms contained required furnishings and lighting. LPA observed required items in bathrooms which were clean. Resident hygiene supplies were properly stored and available. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored and locked. First aid kit contained required items. Facility has designated visitation areas available inside and out. Outside of the facility toured. LPA observed a self-releasing gate and windows have screens in good repair. Smoke and Carbon Monoxide detectors present and in working order. Fire extinguisher date 8/23/23. LPA conducted resident and staff file reviews including medication audit and interviews.

There were no citations during this inspection.

An exit interview was conducted and a copy of this report was provided to AD whose signature confirms receipt.

LPA requested the following updated forms faxed to CCLD by 12/12/23: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan LIC610E, Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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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