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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 540408854
Report Date: 07/15/2022
Date Signed: 07/15/2022 11:35:35 AM

Document Has Been Signed on 07/15/2022 11:35 AM - 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:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lupe Martinez
Kyrstyn Martinez		TIME COMPLETED:
11:41 AM
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On this date 7/15/2022, Licensing Program Analyst (LPA) M. Medina conducted an Annual Required Inspection. LPA met with Licensee, Lupe Martinez and Kyrstyn Martinez, Program Manager. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point, all staff and visitors enter through front door.

Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to resident and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Resident bedrooms toured, all rooms are shared with a minimum of 6 feet between beds. LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Facility staff was observed with mask on.

Licensee to submit LIC 500 (Personnel Report), LIC 610 (Emergency Disaster), and LIC 9020 (Register of Facility Clients) to Department no later than 7/29/2022.

No deficiencies were observed. Exit interview was conducted. Report signed during inspection and a copy left for facility file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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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