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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247204141
Report Date: 04/27/2022
Date Signed: 04/27/2022 12:18:14 PM

Document Has Been Signed on 04/27/2022 12:18 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:C AND D'S GUEST HOME #6FACILITY NUMBER:
247204141
ADMINISTRATOR:DOBBINS, CHANTEFACILITY TYPE:
735
ADDRESS:6314 ATWATER JORDAN RDTELEPHONE:
(209) 357-5195
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY: 6CENSUS: 1DATE:
04/27/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Administrator, Lacey JacksonTIME COMPLETED:
12:25 PM
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On 04/27/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Lacey Jackson. Facility has one central entry and exit and has implemented a sign in policy for visitors.

Facility tour conducted with Administrator. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Resident bedroom is single occupant.

LPAs checked residents’ locked medications and observed a 30-day supply. Food supply was checked. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 05/11/2022: 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 (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020) Surety Bond.

No deficiencies issued during today's inspection. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Lacey Jackson, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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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