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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200250
Report Date: 04/27/2022
Date Signed: 04/27/2022 04:16:49 PM

Document Has Been Signed on 04/27/2022 04:16 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:FERNANDEZ GUEST HOUSEFACILITY NUMBER:
275200250
ADMINISTRATOR:HONESTO R. FERNANDEZFACILITY TYPE:
735
ADDRESS:1007 POLK STREETTELEPHONE:
(831) 443-8746
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 4DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Administrator Honesto FernandezTIME COMPLETED:
04:30 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Administrator Honesto Fernandez and discussed the purpose of the visit. LPA and Administrator Honesto Fernandez began the tour at the front entrance/office of the facility. Facility has a mitigation plan however needs to submit plan on the LIC 808 by a week from today's date.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed to be locked in the garage. LPA observed the following personal protective equipment in office; face shield, gloves, and masks. Facility has not trained staff on infection control. LPA observed all facility staff wearing masks.

Resident’s files have updated emergency contact information.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
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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