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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167202904
Report Date: 04/22/2022
Date Signed: 04/22/2022 08:13:27 PM

Document Has Been Signed on 04/22/2022 08:13 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:CHESTER CARE HOMEFACILITY NUMBER:
167202904
ADMINISTRATOR:CHESTER, FLORAYFACILITY TYPE:
735
ADDRESS:1855 W PARKSIDETELEPHONE:
(559) 583-6483
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY: 5CENSUS: 3DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Floray ChesterTIME COMPLETED:
02:45 PM
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On 4/22/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Administrator Floray Chester.

Visitor log-in/temperature check station was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff were observed with mask covering.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Common areas were properly furnished and well-lit throughout. Fire extinguisher was observed with a purchase date of: 5/24/2021. Chemicals and cleaning supplies are kept in a locked laundry area. Linens and hygiene products were observed. A 2-day supply of perishable and 7-day supply of non-perishable food was observed to be properly stored and labelled. Additional food was kept in a refrigerator in the garage. Resident's Bedrooms were observed to be adequately furnished with bed, dresser, and adequate lightning.

No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 4/29/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC
309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel
Report (LIC500), Register of Facility Clients/Residents for (LIC9020).

An exit interview was conducted with Staff. As a COVID-19 precautionary measure, a copy of this report will be provided via email. Report signed on-site by Facility representative.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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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