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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203255
Report Date: 10/21/2021
Date Signed: 10/21/2021 08:18:34 PM

Document Has Been Signed on 10/21/2021 08:18 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:MARIPOSA ARFFACILITY NUMBER:
157203255
ADMINISTRATOR:SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:1106 MINTER AVENUETELEPHONE:
(661) 758-5331
CITY:SHAFTERSTATE: CAZIP CODE:
93263
CAPACITY: 4CENSUS: 4DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
06:45 PM
MET WITH:House Manager Esmeralda Balderas;TIME COMPLETED:
08:30 PM
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An Annual Inspection Control visit was conducted on the date & times indicated above by LPA K. Mcclurg. LPA met with House Manager (HM) Esmeralda Balderas. LPA reviewed the purpose of the visit with HM.

Facility tour conducted. 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 observed to be posted, including in bathrooms with hand washing techniques. Soap & paper towels available. Hand sanitizer available on entry & throughout the facility. Face coverings in use. Infection control policies & procedures & practices in place & currently applied.

No deficiencies issued.
Exit interview conducted with HM. Report Provided

Continued.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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: MARIPOSA ARF
FACILITY NUMBER: 157203255
VISIT DATE: 10/21/2021
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Continued from Page 1.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Residential Facility (ARF):


· Corporation Board Resolution: Identifies who (individual by name & title) may represent and sign on behalf of the licensee;
· LIC 308 Designation of Facility Responsibility;
· LIC 309 Administrative Organization;
· LIC 400 Affidavit Regarding Client/Resident Cash Resources;
· LIC 402 Surety Bond;
· LIC 500 Personnel Report;
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities;
· LIC 9020 Register of Facility Clients/Residents Please include date of birth (DOB) & Admission Date (Admin Date);
· Copy of current Administrator Certificate(s);
· Alternate contact information including name(s), telephone number(s), & email address(es);

Please submit the above forms/information to Fresno CCL by: Sunday, November 7, 2021

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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