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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209226
Report Date: 11/13/2023
Date Signed: 11/13/2023 12:14:58 PM

Document Has Been Signed on 11/13/2023 12:14 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: 4DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Kari GaitherTIME COMPLETED:
12:15 PM
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On 11/13/2023, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA allowed entrance by Licensee, Kari Gaither.

Currently, four residents in placement. All residents were at day program at time of inspection. Residents attend day program Monday- Friday 8:00 AM - 2:00 PM.

LPA conducted a complete tour of the facility with Licensee. Facility was observed at a comfortable temperature, clean, in good repair. The tour started in the residents' rooms. Residents bedrooms were observed to be adequately furnished with bed, dresser, and adequate lightning. Kitchen toured, LPA observed to have adequate supply for residents in care. Bathrooms were properly equipped and fixtures operational. Hot water was tested at 109 degrees F in the bathrooms. Common areas were properly furnished and well-lit throughout. All medications observed to be locked and stored in entry closet. Medications observed to have original labels and be administered as prescribed.

Fire extinguisher was observed with a service date of 3/14/2023. Carbon monoxide and smoke detectors were tested and observed to be operational. Cleaning supplies and chemicals were observed in the locked in cabinet in garage.

Outside toured. All exits open free of obstruction. No hazards observed.

No deficiencies observed. Exit Interview conducted. A copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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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