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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209231
Report Date: 05/25/2022
Date Signed: 05/25/2022 11:13:14 AM

Document Has Been Signed on 05/25/2022 11:13 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:DE BOER HOME #1FACILITY NUMBER:
547209231
ADMINISTRATOR:DE BOER, BREANNFACILITY TYPE:
735
ADDRESS:1030 N BELMONTTELEPHONE:
(559) 350-3695
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 0DATE:
05/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Breann De BoerTIME COMPLETED:
11:18 AM
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Licensing Program Analyst (LPA) M. Medina made an Announced Pre-licensing on this date. LPA introduced self and allowed entrance by Breann De Boer, Licensee/Administrator.

This pre-licensing visit is a request for change of location for Facility #547208862.

LPA Medina toured facility: All resident will have private bedrooms. All common areas have adequate seating available for residents. Kitchen has plates, cups, utensils, pots and pans. Hot water measured 106 degree F. Bathrooms toured. Securely fastened grab bars were observed and are present near office area all showers. Tub/Showers have non-skid mats. Medications to be stored and secured back . Two (2) fire extinguishers present with a service date of 04/19/22, one located in kitchen and the other near garage door. Facility has a pull station and equipped with fire door/sprinkler system. System observed operational during today's inspection. and observed . Carbon monoxide detector present and observed operational.

All required postings are posted. Facility phone number will be (559) 793-2693 upon relocation. Temporary facility number is (559) 350-3695.

Outside of facility toured. All fire exits open freely and are free of obstruction.

LPA 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.

No hazards observed.

Exit interview conducted.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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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