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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209166
Report Date: 09/16/2021
Date Signed: 09/16/2021 09:17:25 PM

Document Has Been Signed on 09/16/2021 09:17 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:GURROLA CARE HOME #4FACILITY NUMBER:
547209166
ADMINISTRATOR:GURROLA, MARY ELLENFACILITY TYPE:
735
ADDRESS:8 EAST GIBSONTELEPHONE:
(559) 719-7484
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 4DATE:
09/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Andrea DuranTIME COMPLETED:
03:40 PM
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Licensing Program Analysts (LPA) M. Medina conducted an announced Pre-licensing inspection on this date. LPA Medina met with Licensee, Mary Ellen Gurrola and Andrea Duran. This address is currently licensed for 4 residents.

LPA toured facility. Common rooms have adequate furnishings and lighting. All of the resident bedrooms have required furnishings and adequate lighting. Hot water temperature measured at 108 degrees F. LPA observed a supply of extra bed linens and personal hygiene and grooming products. First Aid kit and manual are present with regulation items. Kitchen observed to have dishes, plates, utensils. Cleaning supplies will be stored in locked cabinet under the sink. Medications will be kept in a locked cabinet in the dining room area. A fire extinguisher is present and has a service date of 4/29/2021. Smoke detectors and carbon monoxide detector tested and observed operational during today's inspection.

Outside of the facility toured. All fire exits open free of obstruction.

All required postings are posted. Facility phone number will be (559) 784-3520.

Component III conducted during pre-licensing inspection.

I have found that applicant has met all pre licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

Pre-Licensing is complete and this facility has no deficiencies.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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