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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209265
Report Date: 05/28/2024
Date Signed: 05/28/2024 01:11:39 PM

Document Has Been Signed on 05/28/2024 01:11 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:KENYON HOME #2, THEFACILITY NUMBER:
547209265
ADMINISTRATOR/
DIRECTOR:		KENYON, DEBRAFACILITY TYPE:
735
ADDRESS:2541 E MARY AVETELEPHONE:
(999) 999-9999
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 6CENSUS: 5DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Assistant Administrator/House Manager (AA) Steve ValverdeTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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An Annual visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Assistant Administrator/House Manager (AA) Steve Valverde. LPA stated purpose of visit & was allowed to proceed with inspection

Physical plant toured. Resident bedrooms toured. Sufficient furnishings & adequate lighting. Resident bathrooms toured. Fixtures operational. Hot water measured @ 113 degrees F. Living & dining rooms sufficiently furnished with adequate lighting. Kitchen sufficiently stocked. Appliances in kitchen & in garage appeared to be clean with no unpleasant odors.

Medications locked. Client medical records & other personal information locked.
Outside area toured. Interior & exterior passageways observed to be clear & free of obstructions. Smoke detectors & carbon monoxide detectors operational. Emergency fire drills conducted.. Fire extinguisher service date: 10/30/2023.

Exit interview conducted with AA. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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