547203429-9-27-2023-24-AS-LSAR-CW4464-20230927184855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547203429
Report Date: 09/26/2023
Date Signed: 09/27/2023 06:49:17 PM

Document Has Been Signed on 09/27/2023 06:49 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 HOME		FACILITY NUMBER:	547203429
ADMINISTRATOR:	GALLEGOS, ANDREA		FACILITY TYPE:	735
ADDRESS:	2764 AZALEA AVE.		TELEPHONE:	(559) 686-2899
CITY:	TULARE	STATE: CA	ZIP CODE:	93274
CAPACITY: 4		CENSUS: 4	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Andrea Gallegos, Administrator		TIME COMPLETED:	05:15 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	On 09/26/23, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. Administrator provided a tour of the facility inside and out. LPA observed 4 residents in care at the time of visit. Facility is a 4 bedroom 2 bathroom home. Residents bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Facility temperature was 72 degrees F. Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 116 degrees F. Medications were observed to be locked in the hall closet. Cleaning supplies were observed to be locked under the kitchen sink. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. There are no residents with Restricted Health conditions in the facility. Carbon monoxide and smoke detectors were tested and observed to be operational. Night lights were observed in the hallways. Fire Extinguisher was observed with a service date of 08/30/23. First aid kit was observed and contained all required items. Internet devices and a working phone line were observed to be available for residents in care. (Continued on LIC 809-C)

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ANDREA GALLEGOS HOME	FACILITY NUMBER: 547203429
	VISIT DATE: 09/26/2023

NARRATIVE

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(Continued from 809)

The exterior tour of back yard was conducted and found to be free from debris. A covered outdoor seating area was observed for residents in care. Side gate was self-closing and self-latching.

Residents’ files were reviewed and observed to have update emergency contacts, Admission agreement, and current physician report/individual performance plans (IPP).

The following documents are requested and submitted to Fresno CCL by: 10/15/23:
LIC 308, LIC 400, LIC 402, LIC 500, LIC 610D, Copy of current Administrator certificate and Emergency and Disaster Plan.

An exit interview was conducted with Administrator. A copy of this report was discussed and provided at the time of visit. No deficiencies cited on today's visit.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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