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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206868
Report Date: 09/16/2021
Date Signed: 09/16/2021 11:02:42 AM

Document Has Been Signed on 09/16/2021 11:02 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:ANGIE EDWARDS RESIDENTIAL SERVICESFACILITY NUMBER:
547206868
ADMINISTRATOR:ANGIE R HUGLE EDWARDSFACILITY TYPE:
735
ADDRESS:2442 W. NANCYTELEPHONE:
(559) 788-1047
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 5CENSUS: 3DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Ryan EdwardsTIME COMPLETED:
11:05 AM
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LPA was met by Ryan Edwards, Licensee and stated the purpose of the visit. A tour of the facility was conducted, COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry at facility entrance/exit point, all staff and visitors enter through front door.

Facility appeared clean with no obstruction or fire clearances issues. Social distancing is maintained in the common area and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Resident bedrooms toured, all resident bedrooms are private.

Fire extinguisher present and has a service date of 06/02/2021. Carbon monoxide detector present and observed to be operational during today's inspection. Water temperature measured at 109 degrees F.

LPA checked residents’ medications and observed a 30-day supply. LPA observed a 2-day of perishable and a 7-day of non-perishable food available. Cleaning and PPE supplies were checked. Staff records were reviewed for infection control training. Mitigation plan submitted and uploaded to Department on 06/25/2021. Angie Edwards serves as facility Administrator certificate #6029828735, expires 1/23/2022. First/CPR expires 03/04/2023.

Licensee to submit the following documents to Fresno Regional Office no later than 9/24/2021: Copy of Administrator Certificate, First Aid, LIC 500, LIC 610, LIC 9020.

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: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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