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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209098
Report Date: 10/24/2023
Date Signed: 10/27/2023 07:57:14 AM

Document Has Been Signed on 10/27/2023 07:57 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: 38DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Kim CabrerosTIME COMPLETED:
12:39 PM
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Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct the Annual Inspection. LPA met with Client Program Coordinator Kim Cabreros and Program Supervisor III Marsha Shoemake and inform them the purpose of the visit.
LPAs observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. LPA introduced self and allowed entrance by staff. All COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry.

M. Shoemake brought facility records for review and K. Cabreros provided the facility tour for LPA. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Programming rooms toured, rooms observed to have all required accommodations. Kitchen area toured.

Smoke detector and carbon monoxide detectors observed operational during inspection. Fire extinguisher present with a service date of 9/2023. Water temperature observed to measure at 114 degrees F.

No deficiencies were observed
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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