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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203429
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:56:10 PM

Document Has Been Signed on 07/26/2021 03:56 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:ANDREA GALLEGOS HOMEFACILITY NUMBER:
547203429
ADMINISTRATOR:GALLEGOS, ANDREAFACILITY TYPE:
735
ADDRESS:2764 AZALEA AVE.TELEPHONE:
(559) 686-2899
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 4CENSUS: 4DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Andrea Gallegos, LicenseeTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Lady Cabrera conducted an Annual Inspection on this date. LPA was met by Licensee Andrea Gallegos 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. Bathroom haa trashcan with lid. Hand washing posters were observed by the bathroom and near kitchen sink. Bedrooms were checked and beds are six feet apart.

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. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

No deficiencies were observed. Technical Assistance was provided regarding N95 respirator fit testing for all adult and senior care facilities. . Exit interview was conducted. Licensee was informed that as a COVID-19 precautionary measure, this report will be emailed.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2021
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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