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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 03/16/2022
Date Signed: 03/16/2022 12:41:01 PM


Document Has Been Signed on 03/16/2022 12:41 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:ATWATER RESIDENTIAL CARE FACILITYFACILITY NUMBER:
247209209
ADMINISTRATOR:JOHNSON, JESSICAFACILITY TYPE:
740
ADDRESS:1691 JOE SILVA AVENUETELEPHONE:
(209) 430-1688
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:4CENSUS: 0DATE:
03/16/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Licensee, Jessica Johnson and Administrator, Denise OrdoniezTIME COMPLETED:
12:43 PM
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On 03/16/2022, Licensing Program Analyst (LPA) A. Walton conducted an announced Pre-Licensing / Component III inspection. LPA Walton introduced self, stated purpose of visit, and was allowed entry into the facility. LPA met with:

Licensee: Jessica Johnson

Administrator: Denise Ordoniez

The facility is a 3 Bedroom and 3 Bathroom home and fire clearance was granted for 2 Ambulatory and 2 Non-Ambulatory for a total of 4 Capacity.

LPA toured the facility with Licensee. Common areas were furnished and had adequate seating and lighting available. Bedrooms had required furnishings and are ready for occupancy. LPA observed the smoke detector in bedroom 3 to be detached from the ceiling. The carpet in bedroom 3 was observed to be lifted from the floor and not fully installed. Hot water measured at 129.3 degrees F in the bathroom in bedroom 3, 124.2 degrees F. in the hallway bathroom and 111.3 degrees F. in the Activity bathroom. Grab bars observed to be in the shower area, no grab bars observed by the toilet.

LPA observed a short supply of bed linens and an adequate personal hygiene products. Kitchen was toured and observed to have dishes, plates, and utensils. Cleaning supplies and chemicals were observed to be locked in the laundry room. Medications will be locked in a cabinet in the kitchen. First aid kit was observed and contained all required items. A fire extinguisher was observed and did not have a service date. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching.

CONTINUED TO LIC809C

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209
VISIT DATE: 03/16/2022
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LPA requested Licensee to correct the following items:
  • Reattach smoke detector to the ceiling in bedroom 3
  • Secure the carpet to the floor in bedroom 3
  • Adjust water heater to allow facility water temperature to be within range
  • Have fire extinguisher serviced
  • Obtain additional bed linens to permit changing for once per week that includes blankets and bedspreads.
  • Install grab bars near the toilets

Component III was conducted during today’s pre-licensing visit.

Exit interview conducted. A copy of this report will be provided to Licensee via email due to COVID-19 precautionary measures. Report signed on-site by facility representative.

LPA will notify CAB that facility is ready to be licensed once the above information has been received.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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