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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204067
Report Date: 10/16/2024
Date Signed: 10/16/2024 08:12:34 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/16/2024 08:12 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/
DIRECTOR:		MATA, DEBBIEFACILITY TYPE:
775
ADDRESS:618 MAIN STREETTELEPHONE:
(661) 721-3236
CITY:DELANOSTATE: CAZIP CODE:
93215
CAPACITY: 75CENSUS: 29DATE:
10/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Debbie Mata TIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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On 10/16/24, Licensing Program Analysts (LPAs) M. Medina and L. Salazar arrived to the facility unannounced to conduct the required annual inspection. LPAs arrived, stated the purpose of the visit and were allowed entry into the facility. LPAs conducted facility tour with Program Coordinator, Karina Ramos. Program Director, Debbie Mata arrived a short time later to conduct inspection visit.

LPA Medina reviewed a sample of staff and resident files and observed the files to have the required documentation and staff training's. LPA reviewed Emergency Disaster plan and observed the binder to have the required updated information.

LPA Salazar will document the physical plant tour and inspection tool results on a separate report.

Facility to submit the following documents to Fresno Regional Office no later 11/01/24: LIC 500 (Personnel Report), LIC 9020 (Register of Facility Clients/Residents).

No deficiencies cited.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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