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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209340
Report Date: 01/10/2024
Date Signed: 01/10/2024 12:30:25 PM

Document Has Been Signed on 01/10/2024 12:30 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:DOROTHY WILSON HOMEFACILITY NUMBER:
547209340
ADMINISTRATOR:FROSHOUR, TISHIE MARIEFACILITY TYPE:
735
ADDRESS:3611 W MILLCREEK DRTELEPHONE:
(559) 733-9013
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
01/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tishie Marie Froshour, Administrator TIME COMPLETED:
12:45 PM
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On 01/10/2024, Licensing Program Analysts (LPA) L. Salazar conducted an announced Prelicensing and Component III inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensee, Tishie Marie Froshour.

The facility is 5 bedroom and 3 bathroom home. Fire clearance was granted for 6 Non-Ambulatory for total of 6 capacity. There are 2 residents in care at this time. present during this inspection. Facility temperature is set to 73 degrees .

LPA toured the facility with Licensee. Common areas were furnished and had adequate seating and lighting available. Bedrooms were observed to have required furnishings. Hot water measured at 119 degrees F in client bathroom. LPA observed an extra supply of bed linens and personal hygiene products. Kitchen was toured and observed to have dishes, plate, and utensils. LPAs observed a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. Knives were observed to be locked and secure in a the metal box that is locked in the kitchen cabinet.

Cleaning supplies and chemicals were observed to be in a locked cabinet in laundry room. Medications were kept locked and inaccessible to residents in care. First aid kit was observed and contained all required items. A fire extinguisher was observed and has a service date of 06/23/2023. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection.

Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching. Resident records were reviewed. LPAs observed resident Admission Agreements and Physician Reports. Staff records were reviewed. 5 out of 7 personnel records did not have a criminal record clearance. LPA confirmed in LIS that staff are cleared and associated to the facility. Last fire drill conducted on 01/03/2024.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: DOROTHY WILSON HOME
FACILITY NUMBER: 547209340
VISIT DATE: 01/10/2024
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(Continued from LIC 809)

Component III was conducted during today's pre-licensing visit. Exit interview conducted. A copy of this report was provided to Licensee at the time of visit. LPA will notify CAB that the facility is ready to be licensed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC809 (FAS) - (06/04)
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