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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 540408854
Report Date: 09/03/2021
Date Signed: 09/03/2021 03:52:39 PM

Document Has Been Signed on 09/03/2021 03:52 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:ACACIA HOMEFACILITY NUMBER:
540408854
ADMINISTRATOR:MARTINEZ, LUPEFACILITY TYPE:
735
ADDRESS:783 ACACIA AVETELEPHONE:
(559) 638-6457
CITY:REEDLEYSTATE: CAZIP CODE:
93654
CAPACITY: 6CENSUS: 6DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Lupe MartinezTIME COMPLETED:
11:56 AM
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Licensing Program Analyst (LPA) Melinda Medina arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Licensee Lupe Martinez, the COVID contact questionnaire completed at entry. LPA entered through the central entry point where hand sanitizer and visitor symptom screening was conducted. Mitigation plan submitted and uploaded by Department on 6/25/2021.

Facility Mitigation plan has been approved by CCL. Infection control procedures described in the plan which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, staffing, PPE storage, use and training, and daily infection control procedures. All clients are fully vaccinated.

LPA toured the facility inside and out. Required postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Staff were all observed wearing face coverings. Facility has multiple designated visitation areas available. LPA observed 30-day PPE and resident medication supply. Common and resident bathroom sinks are well stocked with liquid soap for hand washing.

Smoke detectors and carbon monoxide detectors present and observed to be operational. Fire extinguisher present with a service date of 06/09/2021. Water temperature measured at 106 degrees F.

Through LPA’s observations, documentation and record review, the required infection control practices are found to be in compliance. No deficiencies cited during today’s inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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