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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206577
Report Date: 11/17/2023
Date Signed: 11/17/2023 12:52:49 PM


Document Has Been Signed on 11/17/2023 12:52 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:DOMINGO HOME, THEFACILITY NUMBER:
547206577
ADMINISTRATOR:DOMINGO, WALTER OR FEFACILITY TYPE:
740
ADDRESS:2069 LINDA VISTATELEPHONE:
(559) 784-2762
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 4DATE:
11/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Fe DomingoTIME COMPLETED:
01:15 PM
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On 11/17/2023, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA introduced self, stated purpose of visit and allowed entrance by direct care staff. LPA met with Licensee/Administrator Fe Domingo to conduct inspection.

Facility tour conducted with Licensee. Facility tour began in resident bedrooms. Rooms observed to be sufficiently furnished with adequate lighting. Residents bathrooms observed to be clean and in good repair. Bath/tub are have non-skid mats and grab bars. Hot water tested in both bathrooms with a water temperature of 115 degrees F. Dining room and living room have adequate seating and lighting for all residents in care. Tour of kitchen conducted. LPA observed a two day supply of perishable food and a seven day supply of nonperishable food available. All foods and leftovers stored in the refrigerator and/or freezer observed to be properly stored and labeled. All medications observed to be locked and secured in medication area . Medication observed to have all original labels and to be administered as prescribed. All sharps are locked and secured and inaccessible to residents. All cleaning supplies are locked and secured in cabinet.

Outside of facility toured. Seating is available for residents, small shed in backyard is locked, secured and inaccessible to residents. All exits observed to be free of obstruction.

Staff and resident files reviewed. No deficiencies observed. Exit interview was conducted, facility report signed and a copy provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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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