<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201004
Report Date: 08/23/2021
Date Signed: 08/24/2021 09:01:51 AM

Document Has Been Signed on 08/24/2021 09:01 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:SANDOVAL HOMEFACILITY NUMBER:
547201004
ADMINISTRATOR:SANDOVAL, CHRISTINEFACILITY TYPE:
735
ADDRESS:1537 W. LA VIDATELEPHONE:
(559) 636-7678
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 5DATE:
08/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Christine SandovalTIME COMPLETED:
03:36 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) M. Medina conducted an Annual Inspection on this date. LPA was met by Licensee, Christine Sandoval and stated the purpose of the visit. 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.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents 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, resident bedrooms have a minimum of 6 feet between beds.

Fire extinguisher present and has a service date of 05/25/2021. Carbon monoxide detector present and observed to be operational during today's inspection. Hot water measured at 115 degrees F.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Resident’s files have updated emergency contact information. Mitigation plan received and uploaded by Department on 6/24/2021. Christine Sandoval also serves as facility Administrator certification #6022859735, expires 11/30/22.

No deficiencies were observed. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1