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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209027
Report Date: 04/13/2023
Date Signed: 04/13/2023 03:12:41 PM

Document Has Been Signed on 04/13/2023 03:12 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:ASHLEIGH'S HOUSEFACILITY NUMBER:
107209027
ADMINISTRATOR:MCBEE, BRENDA R YFACILITY TYPE:
735
ADDRESS:3088 W NORWICHTELEPHONE:
(559) 273-7193
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 3CENSUS: 3DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ashleigh GarrettTIME COMPLETED:
03:30 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) Brenda McBee.

During this visit, LPA toured the facility. Resident bedrooms have required furnishings, lighting and linens. LPA observed hand washing signs and required items in bathrooms. Resident hygiene supplies were properly stored. Hot water temperature measured at 120 degrees. The kitchen observed clean, in good repair with necessary items and appliances. LPA observed required food supply, paper products and PPE. 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. Doors and passageways are unobstructed throughout the home and outside. Fire Extinguishers dated 8/8/22. Smoke and Carbon Monoxide detectors present and in working order. Emergency & Disaster Plan and Infection Control Procedures reviewed; emergency drill last conducted 4/5/23. Administrator Certification expires 1/18/25. LPA conducted resident and staff file reviews.

AD has agreed to provide a copy of the Infection Control Plan by 4/20/23 as it was unable to be located during the visit.

No deficiencies were cited during this inspection. An exit interview was conducted. A copy of this report was left with AD whose signature confirms receipt of these documents.

LPA requested the following updated forms faxed to CCLD by 4/20/23: Designation of Facility Responsibility (LIC 308), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (LIC 402 if applicable), Personnel Report (LIC 500), Emergency Disaster Plan (610D), Client Roster (LIC 9020), Current Liability Coverage.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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