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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203255
Report Date: 11/15/2023
Date Signed: 11/15/2023 02:19:39 PM

Document Has Been Signed on 11/15/2023 02:19 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) 746-4864
CITY:SHAFTERSTATE: CAZIP CODE:
93263
CAPACITY: 4CENSUS: 4DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Russ SedamTIME COMPLETED:
02:25 PM
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On 11/15/23, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA introduced self and allowed entrance by Administrator Russ Sedam.

Currently, 4 residents in placement. All residents present during today's inspection and observed to be interacting with staff.

LPA conducted a complete tour of the facility with Administrator. Facility was observed at a comfortable temperature, clean, in good repair. Resident rooms toured and observed to have required furnishings. Bathrooms observed in good repair and operational. Showers observed to be equipped with non-skid mats. Hot water was measured at 120 degrees F. Common areas were properly furnished and well-lit throughout. Kitchen observed to have adequate food supply for residents in care. All knives are locked and secured in closet near dining room. Medications observed to be locked and secured in medication cart. All medications observed to have original labels and be administered as prescribed.

Smoke detector and carbon monoxide detector observed operational at time of inspection. Fire extinguisher has a service date of 5/16/23. Last fire drill conducted on 9/27/2023 according to facility records.

Outside toured. All exits open free of obstruction. No hazards observed
.
No deficiencies observed. Exit Interview conducted with Administrator and a copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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