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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208235
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:52:13 PM

Document Has Been Signed on 09/23/2022 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:DE BOER HOME #3FACILITY NUMBER:
547208235
ADMINISTRATOR:DE BOER, BREANNFACILITY TYPE:
735
ADDRESS:2221 W. WHITE CHAPEL WAYTELEPHONE:
(559) 350-3695
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 4DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Breann De BoerTIME COMPLETED:
01:05 PM
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On this date 9/23/22, LPA Medina conducted an Annual Required Infection Control Inspection. LPA was met by Licensee, Breann De Boer. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point, all staff and visitors enter through front door. Facility staff observed to be wearing face masks.

Facility appeared clean and no fire hazards observed. All common areas have adequate seating and lighting for all residents in care. All residents have private bedrooms, resident bathrooms observed to have trash cans with lid.

Fire extinguisher present and has a service date of 3/22/2022. Carbon monoxide detector and smoke detectors present and observed operational during today's inspection.

LPA observed facility to have a 2-day supply of perishable and 7-day supply of non-perishable food available. All medications observed to be locked and secured. All cleaning supplies are locked and secured in laundry room.

LPA received copy of updated LIC 9020 during facility inspection.

No deficiencies were observed. Exit interview was conducted. Report signed during inspection and a copy left for facility file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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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