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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206879
Report Date: 08/07/2025
Date Signed: 08/07/2025 05:50:48 PM

Document Has Been Signed on 08/07/2025 05:50 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DISCOVERY IN THE WESTFACILITY NUMBER:
547206879
ADMINISTRATOR/
DIRECTOR:		ALLEN, TARAFACILITY TYPE:
735
ADDRESS:12143 AVENUE 322TELEPHONE:
(559) 372-8470
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
08/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Daniel Flores-Lopez, Interim Administrator
Leah Martinez, PLAD 		TIME VISIT/
INSPECTION COMPLETED:
05:58 PM
NARRATIVE
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On 08/07/25, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. Administrator on record as of 07/18/25 is Daniel Flores #7028247735 Expiration 12/27/26. Administrator certificate is observed posted on the wall. LPA is currently processing Administrator change.

LPA conducted a tour of the facility, inside and out. Facility is a 4 bedroom 2 bathroom home. Private resident bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction or fire hazards. LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 110 degrees F. Trash can with lid and hand washing postings were observed. Internet device and a working phone line were observed to be available for residents in care. A supply of extra linen's and towels were observed in the hallway.

Carbon monoxide and smoke detectors were observed to be operational. Carbon Monoxide detectors are located in Living Room, kitchen and both hallways leading to the bedrooms. A State Fire Marshall approved automatic fire sprinkler system was observed to be operational. Night lights were observed in the hallways. Fire Extinguisher was observed with a service date of 06/30/25. First aid kit was observed and contained all required items. Resident file was reviewed and observed to have update emergency contact information, Admission agreement, and current medical assessment, Individual Performance Plans, Individual Behavioral Support Plans, and an Individual Emergency Intervention Plan and Needs and Service plans.

(Continued on 809-C)
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Lisa Salazar
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: DISCOVERY IN THE WEST
FACILITY NUMBER: 547206879
VISIT DATE: 08/07/2025
NARRATIVE
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(Continued from LIC 809)

LPA reviewed P&I records for residents in care. LPA observed 3 out of 3 resident P&I records were to have missing receipts for cash withdrawals. 1 out of 3 residents records were observed missing signatures for the cash withdrawals for the month of April 2025 for Resident R1.

Per California Code of Regulations, Title 22, Division 6, Chapter 6, a deficiency is being cited on the attached 809-D. If not corrected, this poses an potential risk to the health safety and or personal rights of residents in care.

The following annual updated documents were obtained at the time of visit: LIC 308, LIC 400, LIC 402, LIC 500, LIC 9020, LIC 610D. An exit interview was conducted and a copy of this report and appeals rights were discussed and provided to Administrator. POC cleared at the time of visit.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Lisa Salazar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2025 05:50 PM - It Cannot Be Edited


Created By: Lisa Salazar On 08/07/2025 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DISCOVERY IN THE WEST
FACILITY NUMBER: 547206879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)(B)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. (B) The store receipt shall constitute the receipt for purchases made for the client from his/her account.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 Residents records for Personal & Incidentals (P&I). LPA reviewed P&I records for the period of January 2025 through June 2025 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Administrator contacted all staff during the visit with LPA stating all receipts for P&I are required for all residents purchases from today's date moving forward. LPA observed confirmation of staff's notification.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Lisa Salazar
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2025


LIC809 (FAS) - (06/04)
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