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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206628
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:52:19 PM

Document Has Been Signed on 10/14/2021 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:DENTON ADULT HOMEFACILITY NUMBER:
547206628
ADMINISTRATOR:RICKMAN,VERONICAFACILITY TYPE:
735
ADDRESS:1120 W. SAN LUCIA AVE.TELEPHONE:
(559) 281-4821
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 5CENSUS: 4DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Veronica RickmanTIME COMPLETED:
01:03 PM
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On 09/03/2021, Licensing Program Analysts (LPA) M. Medina conducted an unannounced an Annual Required-Infection Control Inspection. LPA allowed entrance by Licensee Veronica Rickman and stated purpose of visit.

LPA conducted a tour of the facility with Licensee. All residents have private bedrooms. Facility observed to be clean and odor free. All common areas have adequate furnishings for residents and well lit. Facility observed to have all medications, locked and secured. Residents have a 30-day supply of medication available. Kitchen toured, a 2-day supply of perishable and a 7-day supply of non-perishable food is available. LPA observed all cleaning supplies to be locked and secured in garage, additional PPE on hand and available. Fire extinguisher present with a service date of 3/24/2021. Smoke detectors and carbon monoxide detectors present and observed operational during inspection.

LPA observed COVID training binder for staff, binders for daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, Completed LIC 808 Mitigation Plan was submitted to Department on 04/22/21.

LPA received updated copies of LIC 500, LIC 610 and LIC 9020 and First Aid card 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: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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