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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209219
Report Date: 07/11/2022
Date Signed: 07/11/2022 11:03:17 AM

Document Has Been Signed on 07/11/2022 11:03 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:KAWEAH HEALTH RUTH WOOD OPEN ARMS HOUSEFACILITY NUMBER:
547209219
ADMINISTRATOR:SALAZAR, DEBORAHFACILITY TYPE:
740
ADDRESS:3234 W. IRIS AVE.TELEPHONE:
(559) 733-0642
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 0DATE:
07/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Deborah Salazar, Director Tiffany Bullock and Supervisor Jacklyn BecerraTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Shawna Doucette arrived to the facility announced to conduct the Pre licensing visit. LPA Shawna Doucette met with Administrator Deborah Salazar, Director Tiffany Bullock and Supervisor Jacklyn Becerra who granted LPA's entry into the facility.

LPA toured facility. Common rooms have adequate furnishings and lighting. All of the resident bedrooms have all the required furnishings and adequate lighting. Hot water temperature in bathrooms measured at degrees 105F. LPA observed a supply of extra bed linens and personal hygiene and grooming products. Kitchen observed to have dishes, plates, utensils. Cleaning supplies are stored in a locking cabinet in the laundry room. Medications are locked in a medication cart and a locked fridge . First aid kit contains all the required items. A fire extinguisher is present and has a service date of 05/26/2022. Smoke detectors and carbon monoxide were operating. Facility has sprinkler system.

Outside of the facility toured. Exits open free of obstruction. The residence has a delay egress which sounds the indoor alarm. No outside hazards were observed. No pools or bodies of water.

All required postings are posted. Facility phone number will be (559) 625-0139.

Component III was conducted during pre-licensing visit with Applicants.

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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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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