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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200310
Report Date: 05/12/2022
Date Signed: 05/12/2022 03:54:13 PM

Document Has Been Signed on 05/12/2022 03:54 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:LAKE ISABELLA RESPITE CENTERFACILITY NUMBER:
157200310
ADMINISTRATOR:MCANALLY, KIMBERLYFACILITY TYPE:
775
ADDRESS:6405 LAKE ISABELLA BOULEVARDTELEPHONE:
(661) 665-8871
CITY:LAKE ISABELLASTATE: CAZIP CODE:
93240
CAPACITY: 20CENSUS: 1DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Family Service Manager (FSM) Otilia Benavidez; Respite Site Coordinator (RSC) Jose Sosa;TIME COMPLETED:
04:00 PM
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An Annual Inspection Control visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Family Service Manager (FSM) Otilia Benavidez; Respite Site Coordinator (RSC) Jose Sosa.

One central entry point has been designated for universal entry screening. Routine symptom screening including temperature taken & recorded daily for all staff, residents, & visitors.
Infection Control signs are posted,Soap & paper towels available. Hand sanitizer available on entry & throughout the facility. Face coverings in use & available. Sufficient supply of PPEs. Infection control policies & procedures & practices in place & currently applied.

No deficiencies issued.
Exit interview conducted with FSM. Report Provided.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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