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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209442
Report Date: 08/14/2024
Date Signed: 08/14/2024 11:43:12 AM


Document Has Been Signed on 08/14/2024 11:43 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:SGS CARE HOME IFACILITY NUMBER:
107209442
ADMINISTRATOR:STANFIELD, GLADYSFACILITY TYPE:
740
ADDRESS:5414 E BALCH AVETELEPHONE:
(559) 305-8392
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Gladys StanfieldTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct a Pre-Licensing Inspection. LPA met with Administrator (AD) Gladys Stanfield.

LPA began the tour by entering through the front door of the 4 bedroom – 2.5 bathroom – one story home. All required postings were hung. Common areas were found to be well lit with ceiling fans throughout. Furniture was observed to be properly spaced and in good condition. Flooring is intact throughout the home. Smoke and Carbon Monoxide detectors were tested and found to be I working order. The Fire Extinguisher was serviced 2/27/24 by Jorgenson Co. LPA observed additional supply of paper products, bed linens, towels, personal hygiene/grooming products. Resident rooms are found to be in good repair and contained required linens, furnishings, and lighting. The resident bathrooms are clean, in good repair with grab bars and faucets delivering hot water at 110 degrees.

The kitchen was observed to have a supply of dishes, plates, utensils, and cooking items. Food storage areas are clear and appropriate for food preparation. Cleaning supplies, chemicals, and sharps/knives are all locked as required. Appliances were found to be in working order. LPA observed the required food supply. Resident medications are stored in a locking cabinet. The First aid kits contained the required items. Doors and passageways are unobstructed throughout the inside of the home.

Outside of the facility was toured. There is a covered seating area and a self-releasing gate found to be working properly. There is a shed on the side of the home which was locked. LPA observed inside and observed furniture and yard item storage. LPA called and confirmed the facility phone number by calling (559) 389-0953.

See LIC809C for continuation of this report
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SGS CARE HOME I
FACILITY NUMBER: 107209442
VISIT DATE: 08/14/2024
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Emergency Disaster and Infection Control Plans were reviewed, and COMP III was conducted during this visit with AD. The applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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