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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209166
Report Date: 09/23/2022
Date Signed: 09/23/2022 10:56:28 AM

Document Has Been Signed on 09/23/2022 10:56 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:GURROLA CARE HOME #4FACILITY NUMBER:
547209166
ADMINISTRATOR:GURROLA, MARY ELLENFACILITY TYPE:
735
ADDRESS:8 EAST GIBSONTELEPHONE:
(559) 784-3520
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 4DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Mary Ellen Gurrola
Andrea Duran		TIME COMPLETED:
11:12 AM
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On this date 9/23/22, LPA Medina conducted an Annual Required Infection Control Inspection. LPA was met by Licensees, Andrea Duran and Mary Ellen Gurrola, A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point, all staff and visitors enter through front door.

Facility appeared clean with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Resident bedrooms toured, all residents have private rooms.

Fire extinguisher present and has a service date of 4/28/2022. Carbon monoxide detector and smoke detectors present and observed operational during today's inspection.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility staff was observed with mask on.

LPA received copy of updated Infection Control to include Monkey Pox during facility inspection.

No deficiencies were observed. Exit interview was conducted. Report signed during inspection and a copy left for facility file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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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