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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203487
Report Date: 11/13/2023
Date Signed: 11/14/2023 08:20:40 AM

Document Has Been Signed on 11/14/2023 08:20 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: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: 4DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Kari GaitherTIME COMPLETED:
03:20 PM
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On 11/13/23, Licensing Program Analyst (LPA) M. Medina conducted an Annual Required Inspection. LPA allowed entrance by Licensee, Kari Gaither.

Currently, there are four (4) clients in care. All clients were at Day Program at time of visits, clients attend day program Monday - Friday 8:00 AM - 2:00 PM, all transportation provided by day program.

Facility tour conducted. Facility observed to be clean and odor free. Adequate seating and lighting observed in both the living room and dining room. Client bedrooms have all required accommodations. Client bathroom toured, LPA measured water temperature 116 degrees F. Kitchen toured, LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food. Medications observed to be kept in hallway closet. Client medications were reviewed. All medication have their original labels and appear to be administered as ordered. Smoke detectors and carbon monoxide observed to be operational during today's inspection. Last fire drill conducted on 10/09/23 according to facility records.

Outside of facility toured. No hazards observed.

No deficiencies cited during today's visit. Exit interview conducted and a copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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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