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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203255
Report Date: 11/30/2022
Date Signed: 11/30/2022 01:24:56 PM

Document Has Been Signed on 11/30/2022 01:24 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:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Esmeralda BalderasTIME COMPLETED:
01:41 PM
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On 11/30/22, Licensing Program Analyst (LPA) M. Medina arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA introduced self and stated purpose of visit, LPA allowed entrance by House Manager Esmeralda Balderas. LPA observed a central entry point with a visitor sign in sheet, thermometer, surgical masks, supply of hand sanitizer located upon entry. COVID-19 screening includes documented routine symptom screening for visitors and staff is currently being implemented to follow current visitation guidelines.

LPA toured the facility inside and out. Required postings observed throughout the facility. Staff were all observed wearing face coverings. Facility has a minimum of 30 day supply of PPE and resident medications.

Through LPA's observation of documentation and interview with House Manager, the required infection control practices are found to be in compliance. No deficiencies were observed.

Exit interview was conducted, report signed and a copy of this report provided for facility records.

No deficiencies observed
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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