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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206748
Report Date: 10/31/2024
Date Signed: 10/31/2024 11:39:42 PM

Document Has Been Signed on 10/31/2024 11:39 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/
DIRECTOR:		SANDOVAL, CHRISTINEFACILITY TYPE:
735
ADDRESS:13851 AVE 320TELEPHONE:
(559) 636-7688
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 6CENSUS: DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee/Administrator (L/A) Christine SandovalTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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An Annual visit was conducted by Licensing Program Analyst (LPA) K. McClurg. LPA met with Licensee/Administrator (L/A) Christine Sandoval This facility has no open bodies of water such as pools, spa, fountains, etc.

Physical Plant toured. Kitchen appeared to be clean & organized. Knives & cleaning products in separate locked areas making inaccessible to residents. Sufficient supply of perishable & nonperishable food on the premises. Dining & living room sufficiently furnished. Furnishings appeared to be in good repair. Sufficient lighting. Resident bedrooms appeared to be sufficiently furnished with items in good repair & adequate lighting. Linens on beds & additional supplies available as needed. Resident bathroom appeared & smelled to be clean with no unpleasant odors. Fixtures operational. Grab Interior passageways & exits observed to be clear with no obstructions, including exit door in each resident bedroom. Smoke & carbon dioxide detectors operational

Medications observed to be inaccessible to clients & organized. Medication Administration Records (MARs) & Centrally Stored Medication & Destruction Records (CSMDRs) documentation completed & maintained. Resident files maintained. Staff files maintained. Adult Residential Facility (ARF) Administrator Certificate #7034037735 expires: 11/30/25 per 10/31/24 verification through Community Care Licensing Division (CCLD) website: Active Administrator Certificate Holders.

Exit interview conduced with L/A. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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