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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209073
Report Date: 11/23/2020
Date Signed: 11/25/2020 01:52:31 PM

Document Has Been Signed on 11/25/2020 01:52 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:MARIA LOVING CAREFACILITY NUMBER:
247209073
ADMINISTRATOR:PELAYO, CHRISTINA MFACILITY TYPE:
740
ADDRESS:1115 PAYNE AVENUETELEPHONE:
(209) 733-8136
CITY:GUSTINESTATE: CAZIP CODE:
95322
CAPACITY: 6CENSUS: 0DATE:
11/23/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Christina PelayoTIME COMPLETED:
09:15 AM
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On this date, Licensing Program Analyst (LPA) D. Ayers conducted a Tele-visit with Administrator Christina Pelayo via FaceTime due to COVID-19 and precautionary measures. LPA introduced himself and stated the purpose of the inspection. The facility fire clearance is granted from the Gustine Fire Department for 6 non-ambulatory residents.

During virtual tour, LPA observed all passageways and exits to be clear and free from obstruction. The facility had smoke and carbon-monoxide detectors throughout. Fire extinguishers and first-aid kit observed by LPA. A locked cabinet was prepared for medications and sharp items. Storage space was prepared for the keeping of confidential resident and staff documents. Resident bedrooms had required furnishings and were well lit. Resident bathrooms were clean and had secure grab bars and non-slip mats in the showers. Common areas were well lit and provide sufficient seating for residents. The outdoor space was free from hazards, and the gate was secured with a self-latching door. Administrator and Licensee Maria Drumonde completed Component III presentation.

No deficiencies were observed during the inspection. A copy of this report was sent to the administrator via email.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2020
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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