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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209095
Report Date: 02/18/2022
Date Signed: 02/18/2022 10:59:17 AM

Document Has Been Signed on 02/18/2022 10:59 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 HOUSE IIFACILITY NUMBER:
107209095
ADMINISTRATOR:JACOBS, TEMIKA TRINAFACILITY TYPE:
735
ADDRESS:4753 W. MENLO AVETELEPHONE:
(559) 275-3277
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 3CENSUS: 0DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Temika "Kym" JacobsTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Katie Brown arrived at the facility unannounced to conduct the Infection Control Inspection. LPA explained the purpose of the visit met with Administrator (AD) Temika “Kym” Jacobs.
There are currently no residents in care at the facility.

LPA and AD toured the facility inside and out. During the visit, LPA and AD reviewed Infection Control procedures and requirements in accordance with the Mitigation Plan that was submitted previously. Per AD, prior to a resident admission, Infection Control procedures will be placed and implemented.





No deficiencies cited during this visit.


A copy of this report will be emailed to simplyeducated01@yahoo.com and an exit interview was conducted with Administrator.
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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