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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206800
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:05:49 PM

Document Has Been Signed on 04/25/2022 03:05 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:JAY HOMES INC SANGERFACILITY NUMBER:
107206800
ADMINISTRATOR:RICHARDSON, MARYFACILITY TYPE:
735
ADDRESS:698 S DOCKERYTELEPHONE:
(559) 286-6701
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY: 6CENSUS: 6DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tamika Bonner - Lead Staff; Damon Howell Jr. - Direct Support Professional; TIME COMPLETED:
03:15 PM
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An Annual Inspection Control visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA spoke with License -Corp. Officer (L) James Clark. LPA stated purpose of visit. L authorized Tamika Bonner - Lead Staff (LS) & Damon Howell Jr. - Direct Support Professional (DSP) to work with LPA & to sign for receipt of report.

One central entry point has been designated for universal entry screening. Routine symptom screening including temperature taken & recorded daily for all staff, residents, & visitors.
Infection Control signs are posted. Soap & paper towels available. Hand sanitizer available on entry. Face coverings in use & available. Sufficient supply of PPEs. Infection control policies & procedures & practices in place & currently applied.

No deficiencies issued.
Exit interview conducted with LS & DSP. Report Provided.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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