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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 147202751
Report Date: 12/05/2023
Date Signed: 12/06/2023 07:57:22 AM

Document Has Been Signed on 12/06/2023 07:57 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: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: 15DATE:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Adelina Rico and Director of Operations Jenny ParkTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Program Director Adelina Rico and Director of Operations Jenny Park. LPA disclosed the purpose of the inspection and was granted entry into the facility by Program Director Adelina Rico.

A tour of the facility was conducted with Program Director Adelina Rico. The facility was set at 68 F temperature and free of passageway obstructions inside and outside. The water temperature was measured at 120.0 F.

Kitchen was toured. Cleaning supplies were in a locked storage room. Smoke detectors and carbon monoxide detectors were checked and operating. Facility is wired with sprinkler system. Fire extinguishers were charged and had service dates of 06/23/23. Fire drill was last completed on 10/12/23.

Client and staff records were reviewed. Current first aid and CPR were on file for staff.

An exit interview was conducted with the Program Director and a copy of this report with was provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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