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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 147202751
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:08:45 PM

Document Has Been Signed on 06/21/2022 02:08 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:INYO-MONO ASSOCIATION FOR THE HANDICAPPEDFACILITY NUMBER:
147202751
ADMINISTRATOR:RICO, ADELINAFACILITY TYPE:
775
ADDRESS:371 SOUTH WARREN STREETTELEPHONE:
(760) 873-8668
CITY:BISHOPSTATE: CAZIP CODE:
93514
CAPACITY: 30CENSUS: 14DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Executive Director Adelina RicoTIME COMPLETED:
02:15 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Executive Director Adelina Rico and discussed the purpose of the visit. Executive Director Adelina Rico began the tour at the front entrance of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available for clients and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility is in full operation.

Cleaning supplies were observed behind a locked door in janitorial closet. LPA observed the following personal protective equipment in office; hand sanitizer, gown, face shield, gloves, and masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks. Client files have updated emergency contact information.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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