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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209187
Report Date: 04/07/2023
Date Signed: 04/10/2023 08:20:54 AM

Document Has Been Signed on 04/10/2023 08:20 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:ANTHEM IN THE WESTFACILITY NUMBER:
547209187
ADMINISTRATOR:KIMBERLY LYONSFACILITY TYPE:
738
ADDRESS:25164 RD 44TELEPHONE:
(661) 340-4457
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 4CENSUS: 1DATE:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Kimberly Lyons, AdministratorTIME COMPLETED:
01:45 PM
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On 04/07/23, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. Administrator on record is Kimberly Lyons #600424735 Expiration 10/15/24. Administrator certificate is observed posted on the wall.

LPA conducted a tour of the facility, inside and out. Facility temperature was 73 degrees F. Resident was with family at the time of visit. Facility is a 4 bedroom 2 bathroom home. Private resident bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 113 degrees F. Trash can with lid and hand washing postings were observed. Internet device and a working phone line were observed to be available for residents in care. A supply of extra linen's and towels were observed in the hall.

Carbon monoxide and smoke detectors were observed to be operational. Carbon Monoxide detector was located in Living Room. A State Fire Marshall approved automatic fire sprinkler system was observed to be operational. Night lights were observed in the hallways. Fire Extinguisher was observed with a service date of 02/06/23. First aid kit was observed and contained all required items. (Continued on 809-C)
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ANTHEM IN THE WEST
FACILITY NUMBER: 547209187
VISIT DATE: 04/07/2023
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Medications were observed to be locked in a med cart located in the medication room. Cleaning supplies were observed to be in a locked in the garage. The exterior tour of back yard was conducted and found to be free from debris. A covered outdoor seating area was observed for residents in care. Side gate was self-closing and self-latching.

Resident file was reviewed and observed to have update emergency contact information, Admission agreement, and current medical assessment, Individual Performance Plans, Individual Behavioral Support Plans, and an Individual Emergency Intervention Plan and Needs and Service plans.

A sample of staff files were reviewed. LPA reviewed Administrators personnel file and observed required health screening. Staff files were observed to have current First Aid/CPR. Staff are fingerprint cleared and associated to the facility. Quarterly Earthquake & Fire Drill logs were observed for staff. Last Drill was 03/08/23. Mandated Reporting requirements were provided and discussed with Administrator.

The following documents are requested to be submitted to Fresno CCL by: 04/21/23:

LIC 308, LIC 400, LIC 402, LIC 500, LIC 9020, LIC 610D.

An exit interview was conducted and a copy of this report was discussed and provided to licensee. No deficiencies cited on today's visit.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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