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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200879
Report Date: 07/13/2022
Date Signed: 07/13/2022 01:25:48 PM

Document Has Been Signed on 07/13/2022 01:25 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:KENYON HOME #1, THEFACILITY NUMBER:
547200879
ADMINISTRATOR:KENYON, DEBRAFACILITY TYPE:
735
ADDRESS:2511 N. LIBERTY CT.TELEPHONE:
(559) 738-9298
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 4DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Licensee Debra KenyonTIME COMPLETED:
01:45 PM
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On 07/13/2021, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry by Licensee Debra Kenyon.

Facility has one central entry/exit. LPA did not observe a visitor log-in/temperature screening at the entry. LPA observed signs promoting social distancing, cough/sneeze etiquette, hand washing throughout the facility.

Tour started in the Living room and continued to bedrooms and then kitchen. cNo fire clearance issues were observed during this inspection. All pathways, entrances and exits were clear from obstructions. All resident’s rooms toured and observed to be adequately furnished and lit. Bathrooms observed to be stocked with paper towels, Trash bins with lids, and hand washing signs. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in kitchen last serviced on 10/11/2021 and was fully charged. LPA observed a 30-day supply of cleaning supplies located in the Laundry room and garage.

LPA observed a 30-day supply of medications. Medications were observed to be locked and inaccessible to
residents in care. Staff records were reviewed for good health and First Aid. Facility staff were observed without mask. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. No deficiencies issued during this inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 7/20/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. Report signed on-site by Licensee and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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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