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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209231
Report Date: 10/24/2023
Date Signed: 10/24/2023 11:21:19 AM

Document Has Been Signed on 10/24/2023 11:21 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: 5DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Breann De Boer
Elizabeth Lopez Regalado		TIME COMPLETED:
11:33 AM
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On 10/24/23, Licensing Program Analysts (LPA) M. Medina conducted an unannounced Annual Required Inspection on this date where we met with Breann
De Boer, Licensee and Elizabeth Lopez Regalado, Administrator Certificate #6048937735, expires 6/26/2024.

One resident present during today's inspection, the remaining residents were at day program at time of inspection.

Facility toured inside and outside. Facility observed to be clean, odor free, and at a comfortable temperature. All resident bedrooms have the required furnishings. Linen observed to be clean and in good repair. Additional linen supply available in hall closet. Resident bathroom toured. All bathrooms fixtures observed to be in good repair and working. Hot water measured 119 degrees F. All common areas have adequate seating and lighting available for all residents. Medications observed to be stored and secured in medication area. Medications observed to have original labels and be administered as prescribed.

The fire extinguisher present and current. Carbon monoxide present and observed operational during inspection. Facility is equipped with a pull station and sprinkler system. The last fire drill was conducted on 10/19/23 according to facility records.

Resident and staff files reviewed. LPA received copy of Administrator Certificate and CPR card during inspection.

No deficiencies observed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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