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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209098
Report Date: 11/17/2021
Date Signed: 11/17/2021 11:19:29 AM

Document Has Been Signed on 11/17/2021 11:19 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:PORTERVILLE SHELTERED W/S #2 (BEHAVIOR MOD)FACILITY NUMBER:
547209098
ADMINISTRATOR:GAITHER, ESMERALDAFACILITY TYPE:
775
ADDRESS:194 WEST POPLAR AVENUETELEPHONE:
(559) 784-1399
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 193CENSUS: 22DATE:
11/17/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Administrator, Esmeralda GaitherTIME COMPLETED:
11:20 AM
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On 11/17/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced at the above facility to conduct an Annual Inspection-Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Esmeralda Gaither.

LPA conducted a facility tour with Administrator. There are 22 clients present during this inspection. Facility staff and clients observed to be wearing facial coverings. Facility also offers programs virtually. Facility is cleaned and sanitized daily. Facility has one central entry and exit. Clients observed to be distanced at least 6 feet apart in the activity rooms. Facility is not currently documenting client and staff temperatures. LPA did not observe signs promoting hand-washing and social distancing. Hand sanitizer is readily available throughout the facility. Bathrooms are stocked with paper towels and liquid soap. LPA observed a 30 day supply of PPE and cleaning supplies. LPA observed the isolation room. Lunch is not provided, clients bring meals from home.

The facility utilizes a digital filing system called Case Magic. Staff and client records are uploaded into the system. Client records observed to have updated emergency contact information.

No deficiencies observed.

An exit interview was conducted. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site by Facility Representative.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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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