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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209496
Report Date: 07/03/2024
Date Signed: 07/03/2024 11:40:21 AM

Document Has Been Signed on 07/03/2024 11:40 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:ACACIA HOUSE, THEFACILITY NUMBER:
107209496
ADMINISTRATOR/
DIRECTOR:
MCBEE, BRENDAFACILITY TYPE:
735
ADDRESS:4399 N CARNEGIE AVETELEPHONE:
(559) 273-7193
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 4CENSUS: 0DATE:
07/03/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:23 AM
MET WITH:Douglas McBeeTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Katie Brown arrived at the facility to conduct a Pre-Licensing Inspection for a change of location. LPA met with Administrator (AD) Douglas McBee. LPA Brown conducted a Case Management visit at the current location 2826 W. San Gabriel Fresno 93705. LPA confirmed the required furnishings, linens, food, cleaning supplies, appliances, resident belongings including hygiene, and home other items that will be brought to this location once licensed.

LPA began the tour by entering through the front door of the 4 bedroom - 2 bathroom – 1 story home. Required postings have been placed in entry way and kitchen. Common areas are clean with ceiling fans, carpet and flooring in good repair. Smoke and Carbon Monoxide detectors were tested and found to be I working order. The Fire Extinguisher was serviced by Fire System Solution on 5/15/2024. Resident rooms are found to be in good repair, appropriate size with functioning ceiling fans and lighting. The resident bathrooms are clean and in good repair with faucets delivering hot water as required.

The kitchen was observed to be clean with new appliances and multiple cabinets for food and other item storage. Counters areas are clear and appropriate for food preparation. Cleaning supplies and other chemicals will be locked in the laundry room closet with code locking door. Sharps/knives are all locked as required in the medication cabinet. Laundry appliances were found to be in working order. Resident medications are stored and locked in a cabinet in the kitchen. First aid kit contains all 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. This home does not have a pool or bodies of water.

See LIC809C for continuation of this report
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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: ACACIA HOUSE, THE
FACILITY NUMBER: 107209496
VISIT DATE: 07/03/2024
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LPA confirmed the facility phone number (559) 271-4775.

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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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