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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208864
Report Date: 07/13/2022
Date Signed: 07/13/2022 03:14:05 PM

Document Has Been Signed on 07/13/2022 03:14 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:HONOR IN THE WESTFACILITY NUMBER:
547208864
ADMINISTRATOR:CHAVEZ, CARLOSFACILITY TYPE:
737
ADDRESS:13531 PERRY DRIVETELEPHONE:
(559) 713-1362
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 2DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Carlos ChavezTIME COMPLETED:
03:30 PM
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On 07/13/2021, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry by Administrator Carlos Chavez.

Facility staff was observed with face coverings. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Social distancing and cough etiquette postings observed in facility. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Fire extinguisher in kitchen was last serviced on 01/13/2022 and was fully charged.

Food supply was checked; LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. All resident’s bedrooms toured and observed to be adequately furnished and lit. LPA toured bathrooms and observed Trash bins with lids and hand washing signs. LPA checked residents’ locked medication and observed a 30-Day supply of PPE and incontinence supplies. Cleaning supplies locked in hallway closet.

Staff records were reviewed for good health and infection control training. Residents’ records reviewed to have updated emergency contact information. No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 7/20/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Staff. Report signed on-site by staff and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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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