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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209246
Report Date: 12/20/2022
Date Signed: 12/20/2022 10:59:26 AM


Document Has Been Signed on 12/20/2022 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:LAURITE SENIOR CARE HOMEFACILITY NUMBER:
107209246
ADMINISTRATOR:IDUSUYI, INNOCENTFACILITY TYPE:
740
ADDRESS:5478 E LAURITE AVETELEPHONE:
(559) 297-6771
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 3DATE:
12/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Innocent Idusuyi, LicenseeTIME COMPLETED:
11:00 AM
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On 12/20/22, Licensing Program Analysts (LPA) M. Yang conducted an announced Pre-licensing / Component III Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry into the facility. LPA met with caregiver Eddiemer Sison. Innocent Idusuyi, Licensee was called and arrived shortly. LPA toured the facility with Licensee.

The facility is a 5 bedroom and 3-bathroom home and fire clearance were granted for 4 Non-Ambulatory and 2 bedridden for a total capacity of 6. There are three resident presents during this inspection. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available. Fire extinguisher was observed and had a service date of 09/26/22.

Kitchen was toured and observed to have dishes, plates, and utensils. Knives will be kept locked and secure in the kitchen drawer. Medications were kept locked and inaccessible to residents in care in kitchen shelf. First aid kit was observed and contained all required items. Cleaning supplies and chemicals observed to be stored and locked in garage.

All Bedrooms were observed to have the required furnishing and are ready for occupancy. Hot water measured at 114 degrees F in bathroom 1 and ranged 116 degrees F in the bathroom in the shared bedroom. LPA observed an extra supply of bed linens and personal hygiene products.

Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching. Resident records were reviewed. LPA observed resident Admission Agreements, Physician Reports, and Pre-Appraisal. Smoke detectors and carbon monoxide were observed to be operational during this inspection. Staff records were reviewed. Personnel records have a criminal record clearance.

Component III was conducted during today's pre-licensing visit.

I have found that 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 to Licensee.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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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