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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208825
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:06:19 AM

Document Has Been Signed on 01/20/2023 10:06 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:PEOPLE'S CARE DAMSENFACILITY NUMBER:
547208825
ADMINISTRATOR:KERRI COLEFACILITY TYPE:
735
ADDRESS:6502 W DAMSEN AVETELEPHONE:
(909) 287-3557
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:House Lead, John CastilloTIME COMPLETED:
10:20 AM
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On 01/20/23, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. House Lead, John Castillo contacted Administrator, Tara Allen, via telephone. Administrator did not answer. Facility has one central entrance and exit. Facility has implemented a symptom screening/temperature check for visitors upon entry.

Facility tour conducted with House Lead. Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lids. Hand washing posters were observed by the bathroom sink. Bedrooms are single occupant.

LPA checked residents’ medications. Food supply was checked. Cleaning and PPE supplies were checked. Facility staff was observed with mask on. Resident’s files have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 02/03/2023 Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020) Surety Bond.

No deficiencies issued. A copy of this report was discussed and provided to House Lead, John Castillo, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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