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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208831
Report Date: 10/24/2023
Date Signed: 10/24/2023 04:27:55 PM


Document Has Been Signed on 10/24/2023 04:27 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:GAITHER'S FAMILY HOMEFACILITY NUMBER:
547208831
ADMINISTRATOR:GAITHER, HENRIETTAFACILITY TYPE:
740
ADDRESS:1441 SAN LUCIA AVENUETELEPHONE:
(559) 920-3939
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:4CENSUS: 3DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Melissa KayTIME COMPLETED:
05:12 PM
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Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct the Annual Inspection. LPA met staff Melissa Kay and spoke to Asst. Administrator Kristie Rackley and inform them the purpose of the visit.

LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. LPA introduced self and allowed entrance by DSP staff. All COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry.

Staff M. Kay brought facility records for review and provided the facility tour for LPA. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Resident bedrooms toured, rooms observed to have all required accommodations. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents.

Smoke detector and carbon monoxide detectors observed operational during inspection. Fire extinguisher present with a service date of 2/2023. Water temperature observed to measure at 105 degrees F.

No deficiencies were observed.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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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