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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209058
Report Date: 06/15/2020
Date Signed: 06/15/2020 01:57:51 PM

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:CHRISTINA'S HOME CAREFACILITY NUMBER:
247209058
ADMINISTRATOR:PELAYO, CHRISTINAFACILITY TYPE:
740
ADDRESS:8397 KIMBERLY WAYTELEPHONE:
(209) 485-6940
CITY:HILMARSTATE: CAZIP CODE:
95324
CAPACITY:6CENSUS: 5DATE:
06/15/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Christina Pelayo, Administrator TIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) S. Moua conducted a Prelicensing Televisit on this date. Televisit was conducted over Facetime with Licensee and Administrator Christina Pelayo. Inspection is for the change of ownership of a current licensed facility. A complete tour, inside and out, was conducted.

Facility was observed at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas were properly furnished and well-lit throughout. The tour started in the bedrooms. Residents bedrooms were observed to be adequately furnished with bed, dresser, and adequate lightning. Mattresses and box springs were in good condition. Bathrooms were properly equipped with non-skid mats and securely fastened grab bars. Hot water was tested between 107 degrees F. An adequate supply of linens and personal hygiene supplies were observed. There are no bodies of water outside. Fire extinguisher was observed with a service date of: 1/23/2020. Carbon monoxide and smoke detectors were tested and observed to be operational. Cleaning supplies and chemicals were observed locked. First Aid Kit was checked and observed to have the required supplies. The tour concluded in the kitchen. A sufficient supply of perishable and non-perishable food were observed. Medications are kept locked and secured. Emergency exit plan, phone numbers, and required postings were observed. A working telephone was present.

Component III was completed. Requirements were met. Pre-licensing is complete and this facility has no deficiencies.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (559) 650-7908
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 580-6596
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020
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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