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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206748
Report Date: 10/12/2022
Date Signed: 10/12/2022 01:12:07 PM

Document Has Been Signed on 10/12/2022 01:12 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:SANDOVAL HOME IIIFACILITY NUMBER:
547206748
ADMINISTRATOR:SANDOVAL, CHRISTINEFACILITY TYPE:
735
ADDRESS:13851 AVENUE 320TELEPHONE:
(559) 636-7688
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 6CENSUS: 4DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Licensee Christine Sandoval TIME COMPLETED:
01:25 PM
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On 10/12/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Licensee Christine Sandoval. LPA conducted a facility tour with Licensee. There are currently no clients present during tour.

Upon entry visitor log-in/temperature check was observed. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility. LPA observed a 30-day PPE supplies.

Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 07/16/22. LPA checked clients’ locked medications.

All clients’ room toured and observed to be adequately furnished and lit. LPA observed 1 shared residents’ bed to be at least 6 feet apart and 2 single occupant room. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks.

The exterior tour was conducted. Outside free of obstruction. Staff records were reviewed for good health. All clients’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 10/18/22. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 610D, Lic 9282, and Administrator Certificate. A copy of this report was provided to Licensee.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
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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