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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208863
Report Date: 10/24/2023
Date Signed: 10/24/2023 02:34:00 PM

Document Has Been Signed on 10/24/2023 02:34 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:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Breann DeBoer
Linda Anderson		TIME COMPLETED:
02:50 PM
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On 10/24/2023, Licensing Program Analysts (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit and allowed entrance by Administrator, Linda Anderson. Licensee, Breann DeBoer also present during inspection.

All residents were present at time of inspection. Facility tour conducted with Administrator. Facility observed to be clean, odor free, and at a comfortable temperature. Facility is well lit and has sufficient seating in all common areas. Facility has 3 private bedrooms and 1 shared bedroom. Resident bedrooms observed to have all required furnishings. Additional linen supply available in each resident bedroom and in laundry room. Resident bathrooms toured. All bathroom fixtures observed to be in good repair and working. Hot water measured at 116 degrees F. Bathrooms equipped with grab bars in toilet and shower, showers also have non-skid mats available. Medications observed to be locked and secured in cabinet near dining room. Medications reviewed and observed to have original labels and be administered as prescribed.

The fire extinguisher was serviced on 12/12/2022. Carbon monoxide detectors tested and observed operational during inspection. Facility is equipped with pull station and fire sprinklers. The last fire drill was conducted on 9/19/2023 according to facility records.

Outside toured, no obstructions or hazards observed.

LPA received copies of administrator certificate, cpr/first aid, LIC 500 and LIC 9020 during visit.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
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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