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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208863
Report Date: 05/09/2022
Date Signed: 05/09/2022 01:28:41 PM

Document Has Been Signed on 05/09/2022 01:28 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 #2FACILITY NUMBER:
547208863
ADMINISTRATOR:LINDA ANDERSONFACILITY TYPE:
735
ADDRESS:2211 W ORANGE AVETELEPHONE:
(559) 791-9481
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 5DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Linda AndersonTIME COMPLETED:
01:31 PM
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On 5/09/22, LPA conducted an unannounced Annual Required Infection Control Inspection. LPA allowed entrance by Administrator, Linda Anderson and stated the purpose of the visit. A tour of the facility was conducted. Licensee Breann DeBoer arrived a short time later to complete inspection tour. All 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 appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to resident and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Resident bedrooms toured, resident bedrooms with 2 occupants observed to have a minimum of 6 feet between beds. Food supply observed to be adequate for the residents in care. Cleaning supplies observed to be locked and secured. PPE supplies observed to be secured in the garage.

Fire extinguisher present and has a service date of 11/6/2022. Carbon monoxide detector and smoke detectors present and observed to be operational during today's inspection. Facility is equipped with pull station and fire sprinklers.

Administrator to submit copies updated Administrator's certificate, CPR/First Aid, LIC 500, LIC 610, LIC 9020 to submit to Fresno CCL office no later than 5/16/2022. LPA received copy of facility Infection Control Plan during visit.

No deficiencies observed during inspection. Exit interview conducted. LPA left copy of facility report with licensee.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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