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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209250
Report Date: 10/27/2022
Date Signed: 10/27/2022 12:03:16 PM

Document Has Been Signed on 10/27/2022 12:03 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:MERZOIAN RANCH 2 LLCFACILITY NUMBER:
547209250
ADMINISTRATOR:EVANS, KIMILAFACILITY TYPE:
740
ADDRESS:668 W. WILLOW OAK AVE.TELEPHONE:
(559) 361-5356
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 0DATE:
10/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Kimila EvansTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) L. Xiong conducted an announced Pre-licensing Inspection. I met with Administrator Kimila Evans and Member Manager, Dwayne Story and informed them the purpose of the visit.

The facility was, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Common areas were properly furnished and well-lit throughout. Smoke detectors and carbon monoxide detector were tested and observed to be operational. The First Aid Kit was observed to have the required supplies.

There was a locked cabinet in the kitchen for medications and knives/sharp objects. Cleaning supplies, chemicals, and hazardous materials were stored in the laundry room in a locked cabinet. Resident and personnel files will be stored in a locked facility office.

The residents' bedrooms were observed to be furnished with bed, dresser, night stand, lamp, chair and adequate lightning. Mattresses were in good condition. A sufficient supply of linens and towels was observed.

Bathrooms had non-slip rugs and grip bars equipped in the tubs/showers. Hot water was tested with a thermometer and reflected a temperature of 120 degrees Fahrenheit.

A self-latching gate was also observed.

Component III was conducted and completed. Exit interview was conducted. Pending licensure by Centralized Application Bureau (CAB)
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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