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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203255
Report Date: 11/16/2024
Date Signed: 11/16/2024 02:36:54 PM

Document Has Been Signed on 11/16/2024 02:36 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/
DIRECTOR:
SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:1106 MINTER AVENUETELEPHONE:
(661) 746-4864
CITY:SHAFTERSTATE: CAZIP CODE:
93263
CAPACITY: 4CENSUS: 4DATE:
11/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:11 AM
MET WITH:Pamela CarterTIME VISIT/
INSPECTION COMPLETED:
02:57 PM
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On 11/16/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual required inspection. LPA arrived, introduced self, and stated purpose of visit. LPA allowed entrance by Direct Care staff. House Manager contacted by telephone, and arrived a short time later to conduct facility inspection.

Currently, there are four (4) residents in placement, all residents were present at time of inspection. LPA observed facility to be clean, odor free, and maintained at a comfortable temperature. Facility tour conducted, all resident bedrooms observed to be private bedrooms. All bedrooms, observed to have required furnishings available. Resident bathrooms toured, LPA observed shower chairs, grab bars, and non-skid mats. Water temperature measured at 115 degrees F. Kitchen toured, facility observed to have a 2-day supply of perishable and a 7-day supply of non-perishable available. Kitchen knives observed to be locked and secured in hall closet. Medications observed to be locked and secured in medication cart. LPA observed medication bubble packs to have original labels and to be administered as prescribed

Smoke detector and carbon monoxide detector observed operational at time of inspection. Fire extinguisher has a service date of 9/11/2024 . Last fire drill conducted on 11/09/24 according to facility records.

Outside toured. All exits open free of obstruction. No hazards observed
.
No deficiencies observed. Exit Interview conducted with House Manager and a copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2024
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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