107209222-4-8-2022-24-AS-KBRN-CDAPN6-20220408112725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209222
Report Date: 04/08/2022
Date Signed: 04/08/2022 11:27:48 AM

Document Has Been Signed on 04/08/2022 11:27 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:	HAND IN HAND CARE HOME		FACILITY NUMBER:	107209222
ADMINISTRATOR:	PETIL, DIVINA		FACILITY TYPE:	740
ADDRESS:	4361 W. FREMONT AVE		TELEPHONE:	(559) 389-0315
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	6	CENSUS:	DATE:	04/08/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Divina "Grace" Petil		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct the Pre-Licensing Inspection (Change of location). LPA met with Licensee Ronald Sanborne and Administrator Divina “Grace” Petil. LPA began the tour by entering through the front door of the home. All required are displayed and observed upon entry. LPA observed Covid-19 Health Screening area and visitor sign in. Furniture and flooring in common rooms observed to be in good repair with adequate lighting throughout. Resident bedrooms have the required furnishings, lighting and bed linens. Smoke and Carbon Monoxide detectors present and in working order. LPA observed supply of extra bed linens, towels, and personal hygiene/grooming products. Hot water temperature in resident bathroom measured at 105 degrees F. LPA observed hand soap, paper towels, garbage cans and grab bars in resident bathrooms. Kitchen observed to have supply of dishes, cups, plates, utensils, pots and pans and cooking utensils in good repair. LPA observed a 7 day of non-perishable and 2 day perishable food supply. Counter tops and cabinets are clear and appropriate for food preparation. Knives are kept in a locked drawer in the kitchen. Cleaning supplies and chemicals are stored in a locked cabinet in the garage separate from any food items. A Washer and Dryer were observed in the laundry room with additional shelving for storage. Appliances observed to be in working order and at proper temperature. Medications will be stored in a locked kitchen closet along with First Aid Kit and resident/personnel files. The First aid kit contains all required items. A fire extinguisher is present in the kitchen dated 1/22/2022. Doors and passageways are unobstructed throughout the home. See LIC809-C for continuation

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HAND IN HAND CARE HOME	FACILITY NUMBER: 107209222
	VISIT DATE: 04/08/2022

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Pre-Licensing Report continued

LPA toured the outside of the facility. The home does not have a pool, bodies of water or other hazards. Outdoor activity space with shaded areas and seating were located on the backyard patio. LPA observed a self-releasing gate and windows have screens in good repair. There is a small shed in the back yard that was observed by LPA to be used for furniture and holiday decoration storage.

Component III was conducted during the visit with the Licensee and Administrator.

LPA called the designated facility phone (559) 389-0315. The phone is set up and in working order.

The applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

A copy of this report was provided, and an exit interview was conducted with the Licensee and Administrator

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC809 (FAS) - (06/04)

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