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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202830
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:55:47 PM

Document Has Been Signed on 10/14/2021 03:55 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:HEATHERWOOD HOMEFACILITY NUMBER:
547202830
ADMINISTRATOR:RICKMAN, VERONICAFACILITY TYPE:
735
ADDRESS:300 E HEATHERWOOD CIRTELEPHONE:
(559) 281-4821
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 5CENSUS: 4DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Veronica RickmanTIME COMPLETED:
03:54 PM
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Licensing Program Analyst (LPA) M. Medina conducted an Annual Required-Infection Control Inspection on this date. LPA was met by Licensee/Administrator Veronica Rickman and stated the purpose of the visit. LPA observed COVID-19 guidelines to be 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.

LPA checked residents' medications and observed a 30-day supply. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food available in facility. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on.

LPA received copies of LIC 500, LIC 610, LIC 9020 and First Aid certificate during inspection visit.

No deficiencies were observed. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed. Report was signed by staff.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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