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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203487
Report Date: 10/12/2022
Date Signed: 10/12/2022 01:33:04 PM

Document Has Been Signed on 10/12/2022 01:33 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:KG'S CARE HOMEFACILITY NUMBER:
547203487
ADMINISTRATOR:GAITHER, KARIFACILITY TYPE:
735
ADDRESS:586 N. BALMORALTELEPHONE:
(559) 784-3498
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 3DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Kari GaitherTIME COMPLETED:
01:50 PM
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On 10/12/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection visit. LPA Medina met by Licensee, Kari Gaither and stated purpose of visit. All COVID-19 guidelines remain in practice, a sign in sheet and temperature check available upon entry. Staff observed to be wearing masks during inspection.

Facility toured, all common areas observed to have adequate seating for residents. Kitchen toured, facility has a 2-day supply of perishable food and a 7-day supply of non-perishable food available. Resident bedrooms toured, all bedrooms are private and have required furnishings. Resident medication observed to be locked and secured in hall closet and have a 30-day supply available.

All fire exits are free of obstructions. Fire extinguisher present with a service date of 03/09/2022. Carbon monoxide and smoke detectors present and observed operational. Personal Protective Equipment (PPE) on site and available.

LPA received copies of Administrator certificate, and LIC 500 during facility inspection.

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: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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