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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209098
Report Date: 07/26/2022
Date Signed: 07/26/2022 10:42:02 AM

Document Has Been Signed on 07/26/2022 10:42 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: 60DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Esmeralda GaitherTIME COMPLETED:
10:55 AM
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On 7/26/22, Licensing Program Analysts (LPAs) M. Medina and V. Gorban conducted an unannounced Annual Required Infection Control inspection. LPAs introduced self and stated purpose of visit. LPAs allowed entrance and conducted inspection with Esmeralda Gaither, Program Supervisor. Facility has one main entrance for all visitors, COVID-19 visitor sign-in, temperature check and hand sanitizer observed at entry. All facility staff and clients observed to be wearing masks.

Day Program toured. All clients observed to be engaged in small group activities. Hand sanitizer available throughout facility. Bathrooms toured, all bathrooms stocked with hand soap and paper towels, hand washing signs posted near sinks. Facility is disinfected throughout the day. No meals are prepared on site, all residents bring meals daily. No medication is stored or administered at day program. PPE is available on site. All chemicals are locked and secured in cabinet in storage room. Facility is equipped with pull stations and emergency strobe lights. Last fire drill was conducted on 6/30/22 . Fire extinguishers on site have a service date of 9/08/21.

No deficiencies observed or cited during today's inspection.

Exit interview conducted. Facility report signed on site and a copy of this report left for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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