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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208928
Report Date: 05/09/2022
Date Signed: 05/09/2022 03:43:14 PM

Document Has Been Signed on 05/09/2022 03:43 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:GAITHERS FAMILY HOME #2FACILITY NUMBER:
547208928
ADMINISTRATOR:MCDONALD, ANNAFACILITY TYPE:
735
ADDRESS:590 W MCCOMB AVETELEPHONE:
(559) 686-2663
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 5DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Samantha RobinsonTIME COMPLETED:
03:57 PM
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On 5/9/2022, LPA Medina conducted an unannounced Annual Required Inspection. LPA introduced self and allowed entrance by Direct Care Assistant (DCA), Samantha Robinson. LPA contacted Administrator, Anna McDonald by telephone and she was not available for today's inspection. A tour of the facility was conducted. 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. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid, hand washing posters observed near sink, paper towels and hand soap available. Resident rooms toured, shared bedroom observed to have at least 6 feet between beds, all bedrooms observed to have required furnishings. Food supply observed to be adequate for residents in care.

Fire extinguisher present with a service date of 2/18/2022. 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. Water temperatures measured at 111 degrees F.

Administrator to submit copies of current Administrator Certificate, CPR/First Aid, LIC 500, and LIC 9020 to Fresno CCL office no later than 5/16/2022.

No deficiencies observed during today's inspection. Exit interview
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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