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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208928
Report Date: 11/21/2023
Date Signed: 11/21/2023 11:55:40 AM

Document Has Been Signed on 11/21/2023 11:55 AM - 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:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Connie VillarrealTIME COMPLETED:
12:14 PM
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On 11/21/23, Licensing Program Analyst (LPA) M. Medina made an unannounced Annual Required inspection. LPA introduced self, stated purpose of visit, and allowed entrance by House Manager, Connie Villarreal. Administrator, Anna McDonald contacted by telephone and not available to conduct today's inspection. Anna McDonald, Administrator Certificate #6019096735, expires 1/24/2024.

Currently, 5 residents in care. All residents were present at start of inspection. Facility operates daily activities with clients in home.

Facility tour conducted both inside and outside. Facility observed to be a comfortable temperature, and in good repair. Residents bedrooms have all required accommodations. Facility has 2 shared and 1 private bedroom. Living room and dining room areas have adequate seating and lighting for all residents in care. Client bathroom toured, LPA observed non-skid mats and shower chair available, water temperature measured at 112 degrees F in bathroom. Kitchen tour conducted, LPA observed adequate amount of food for residents in care. Medications observed to be locked and secured in medication area. All medications observed to have original labels, and to be administered as prescribed. Fire extinguisher last serviced 3/22/23, smoke detectors and carbon monoxide detectors observed operational during today's inspection. Facility is equipped with a pull station and sprinkler system. According to facility records, the most recent fire drill was conducted on 9/15/23.

Outside tour of facility conducted. All fire exits open freely and are free of obstruction. No hazards observed.

LPA conducted interviews and reviewed staff and resident files during inspection.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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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