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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204067
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:24:21 PM

Document Has Been Signed on 10/30/2023 02:24 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:POSITIVE SUPPORTSFACILITY NUMBER:
157204067
ADMINISTRATOR:MATA, DEBBIEFACILITY TYPE:
775
ADDRESS:618 MAIN STREETTELEPHONE:
(661) 721-3236
CITY:DELANOSTATE: CAZIP CODE:
93215
CAPACITY: 75CENSUS: 31DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Debbie Mata, Administrator TIME COMPLETED:
02:40 PM
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On 10/30/23, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct the required annual inspection. LPA was greeted by Administrator, stated the purpose of the visit, and was allowed entry into the facility.

LPA toured the facility inside and out. LPA observed the required hand washing signs in client restrooms. An updated Infection Control plan was received prior to LPA's inspection. LPA observed the facility to be clean and free from odor. Facility temperature measured at 72 degrees F. Disinfectants and cleaning supplies were observed to be locked in laundry room, inaccessible to clients.

Emergency disaster plan and procedures are in place. Last fire drill was conducted on 10/11/23. Doors and passageways were observed to be free from obstruction throughout the program. Fire extinguishers were observed with a service date of 09/18/23. A sample of client and staff files will be reviewed at a later date.

LPA requested the following updated forms to be faxed to CCLD by: 11/13/23: Designation of Facility Responsibility (LIC308), Personnel Report (LIC 500), Client Roster (LIC 9020), and Emergency Disaster Plan (LIC 610D). No deficiencies cited on today's visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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