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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209387
Report Date: 11/19/2024
Date Signed: 11/19/2024 12:36:39 PM

Document Has Been Signed on 11/19/2024 12:36 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CAROL'S HOMEFACILITY NUMBER:
107209387
ADMINISTRATOR/
DIRECTOR:
OPOKU-ABABIO, KOFIFACILITY TYPE:
735
ADDRESS:1133 E SAN MADELE AVETELEPHONE:
(559) 475-4057
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 4CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Kofi Opoku-AbabioTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 11/19/2024, Licensing Program Analyst (LPA) Daiquiri Boyd made an unannounced visit to the facility for the purpose of conducting an Annual Inspection. LPA was greeted by House Manager(HM) Rahel Assefa, who promptly called Administrator (AD) Kofi Opoku-Ababio. LPA explained the reason for the visit to HM.

During the visit, LPA toured the home inside and out. LPA observed the living room area of the home to be clean and free of hazards or obstructions, flooring was clean and in good repair. No fireplace was observed. Large sliding glass door to the backyard area was clean and properly working. Kitchen area was clean, counter tops were granite and clean, flooring was laminate wood and clean and all was in good repair. There was a table for eating that sits four people, also in good repair. The bathrooms were inspected and found to be in good repair and working order. Water was tested at the bathroom tap and was found to be at 105.6 degrees F. Smoke, fire and carbon monoxide detectors were all tested and found to be operating properly. The home has four residents, each in a single occupancy room. Each resident room is furnished with a bed, a dresser, a chair, a working light and ceiling fan, and a closet for their clothing and personal belongings. All hallways and passageways were clean and clear of obstruction, there are no hazards observed. The garage was clean and in new condition, an extra freezer was observed in the garage with extra meat and bread stored, as well as convenience foods. All doors and windows to the home are working properly. There is a hallway closet where personal hygiene items are kept locked. All medications are kept in a locked file cabinet in the kitchen. Fire extinguisher was serviced on 9/9/2024 and is kept in the kitchen. Disinfectants and cleaning supplies are kept in a locked hallway cabinet. Washer and dryer are located in a hallway closet. First Aid kit was observed to be complete. Fire and emergency drill was last conducted on 7/22/24. Food was of ample supply for 7 days for the 4 residents at the home.

Upon exiting the home into the backyard area, LPA observed a swimming pool that was clean and fenced off with a metal pool fencing that was bolted into the ground, fence is approximately 5'2" high. LPA observed the gate to be locked and in operating order. Perimeter fencing gates opening to the front yard were easily opened and had self closing latches that were in good working order. (Continued on next page)
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CAROL'S HOME
FACILITY NUMBER: 107209387
VISIT DATE: 11/19/2024
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There were no deficiencies cited on this day.

LPA requested the following updated forms faxed to CCLD by 11/29/24: Designation of Facility
Responsibility (Lic308), Administrative Organization (Lic309), Surety Bond (Lic402), Emergency Disaster Plan LIC610D, Personnel Report (LIC500), Proof of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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