<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209220
Report Date: 05/15/2023
Date Signed: 05/15/2023 11:45:04 AM


Document Has Been Signed on 05/15/2023 11:45 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:JEFFRIES HOME RCFEFACILITY NUMBER:
547209220
ADMINISTRATOR:SEARCY, KIMFACILITY TYPE:
740
ADDRESS:2545 W WHITE CHAPEL AVETELEPHONE:
(559) 359-3671
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 6DATE:
05/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Jennifer JeffriesTIME COMPLETED:
12:19 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Today, Licensing Program Analyt L. Xiong arrived at the facility unannounced to conduct the . LPAs met with Licensee/Administrator Jennifer Jefferies informing her the purpose of the visit.

Mitigation plan has been submitted Licensing. Infection control procedures described in the plan and observed by LPAs include: Daily symptoms screenings (for staff, persons in care and visitors), visitation policy, quarantine/isolation procedures, surveillance testing, infection control plan and identification of Kim Searcy as the Infection Control Lead, emergency staffing, PPE use, infection control training and procedures, documentation, postings and communication. LPAs reviewed Mitigation Plan and procedures with the House manager and Administrator.

LPAs toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed in the facility. Staff were all observed wearing face coverings. Facility has designated visitation areas. LPAs observed a 30 day supply of PPE and resident medications. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying were observed.

Through LPA’s observations, documentation review and interview with Licensee, the required infection control practices are found to be in compliance. No deficiencies cited on today’s inspection.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1