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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209226
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:23:20 PM

Document Has Been Signed on 04/12/2022 03:23 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:KG'S CARE HOME #2FACILITY NUMBER:
547209226
ADMINISTRATOR:GAITHER, KARIFACILITY TYPE:
735
ADDRESS:976 N. VILLA ST.TELEPHONE:
(559) 359-0535
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 0DATE:
04/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kari GaitherTIME COMPLETED:
03:27 PM
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On 04/12/22, Licensing Program Analyst (LPA) M. Medina conducted an announced Pre-licensing inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensee Kari Gaither. LPA toured the facility with Licensee. The facility is 4 bedrooms and 2 bathrooms home. Fire clearance was granted for 4 ambulatory residents.

Common areas were furnished and had adequate seating and lighting available. Kitchen was toured and observed to have dishes, plate, and utensils. All bedrooms were observed to have required furnishings. LPA observed a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. Knives were observed to be locked and secure in kitchen drawer. Medications will be kept in locked closet. Hot water temperature measured at 111 degrees F. First aid kit was observed and contained all required items. A fire extinguisher was observed and has a service date of 03/09/22.

Cleaning supplies and chemicals were observed to be in a locked cabinet in the laundry room and under kitchen sink. garage. Outside of facility toured. Exits were open and free of obstructions. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection.

Component III was conducted during today's pre-licensing visit.

I have found that the 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: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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