<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208929
Report Date: 05/21/2024
Date Signed: 05/21/2024 01:21:33 PM


Document Has Been Signed on 05/21/2024 01:21 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:GAITHER'S FAMILY HOME #3FACILITY NUMBER:
547208929
ADMINISTRATOR:GAITHER, HENRIETTAFACILITY TYPE:
740
ADDRESS:1302 E CARMELO AVETELEPHONE:
(559) 687-0300
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:6CENSUS: 6DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Nancy ThompsonTIME COMPLETED:
01:33 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/21/24, Licensing Program Analyst (LPA) M. Medina arrived to conduct an Annual Required Inspection. Administer, Anna McDonald contacted by telephone and not available to conduct today's inspection. LPA met with House Manager, Nancy Thompson during today's inspection.

Currently, there are six (6) in care. All residents attend an in home Day Program, Monday-Friday 9:30am - 12:30 pm. Facility toured inside and outside. Living room and dining room have adequate furnishings and lighting. Resident bedrooms have all required accommodations. Residents bathroom observed to be clean and all fixtures working properly. Hot water temperature in bathrooms measured at 118 degrees F. LPA observed a supply of extra bed linens and personal hygiene and grooming products. Kitchen toured, a 7 day of non-perishable and 2 day of perishable available. Medications are locked and secured in medication room. Medications observed to have original labels and to be administered as prescribed.

A fire extinguisher is present and was serviced during today's visit on 3/08/24. Smoke detectors and carbon monoxide detector tested and observed operational. Last fire drill was conducted on 4/2024 according to facility records.

Outside of the facility toured. All exits open free of obstruction. Gate observed to be self latching. No outside hazards were observed.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1