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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150404029
Report Date: 08/30/2022
Date Signed: 08/30/2022 12:16:23 PM

Document Has Been Signed on 08/30/2022 12:16 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:MOORE SMALL FAMILY HOMEFACILITY NUMBER:
150404029
ADMINISTRATOR:GUERRA, CYNTHIA G.FACILITY TYPE:
735
ADDRESS:1101 AUSTIN STREETTELEPHONE:
(661) 725-7570
CITY:DELANOSTATE: CAZIP CODE:
93215
CAPACITY: 6CENSUS: 5DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Administrator Cynthia GuerraTIME COMPLETED:
12:15 PM
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On 8/30/22, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA met with Administrator Cynthia Guerra and stated the purpose of the visit.

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one
entrance/exit point. Facility staff observed with facial coverings. Facility appeared clean with no obstruction or
fire clearance issues. Hand sanitizer was readily available to residents and visitors. Hand washing and other
various Covid-19 related signs were observed in the common areas.

Sharp items and cleaning supplies are kept locked in the living room cabinets. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the hallway was last serviced on 06/03/2022 and was fully charged. PPE supplies are kept in the living room cabinets. Three trash cans observed with lids, rest without. Hand washing posters were observed in the bathrooms by the sink. Staff records were reviewed for infection control training. Resident’s files have updated emergency contact information.

No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 9/06/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC
309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E),
Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. Report signed on-site and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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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