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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201004
Report Date: 04/04/2022
Date Signed: 04/04/2022 11:48:01 AM

Document Has Been Signed on 04/04/2022 11:48 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: 6DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee Christine Sandoval TIME COMPLETED:
10:20 AM
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On 04/04/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with caregiver Jennifer Martinez. Licensee Christine Sandoval was called and arrived shortly. LPA conducted a facility tour with Licensee. There are currently six clients present during tour.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility.

LPA checked clients’ locked medications. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were locked under kitchen sink. All clients’ bedroom toured and observed to be adequately furnished and lit. LPA observed 3 shared client’s bed to be at least 6 feet apart. All bathrooms observed trash bin with lid. Hand washing posting not observed by sinks.

The exterior tour was conducted. Outside area free of obstruction. LPA observed small amount of PPE supplies. Facility 30-day PPE supplies stored at a central location. Staff records were reviewed for good health and infection control training. All clients’ records reviewed to have updated emergency contact information. LPA observed fire extinguisher served date: 05/25/21. Last fire drill: 02/16/22.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 4/12/22. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610D, and Lic 9020. LPA received copy of Administrator Certificate and facility sketch during facility inspection.

Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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