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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204173
Report Date: 09/29/2023
Date Signed: 09/29/2023 10:45:36 AM

Document Has Been Signed on 09/29/2023 10:45 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:FRESNO GUEST HOME #5FACILITY NUMBER:
107204173
ADMINISTRATOR:KUTNERIAN, ANGELICAFACILITY TYPE:
740
ADDRESS:2776 E. MAGILLTELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 6DATE:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Angela KutnerianTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by caregiver staff and explain the purpose of the visit. Administrator Angelica Kutnerian (AD1) and Jaycee Sanderson arrived at the facility a few minutes after. Assistant Administrator (AD2) Jaycee Sanderson was present to assist AD1 with the inspection.

The residence was set at 75 F temperature and free of passageway obstructions inside and outside. LPAs observed six bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition. Hot water temperature was measured at 106 degrees F.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. Medication and knives are locked in the kitchen area. Cleaning supplies were locked in the laundry room. Smoke detectors and carbon monoxide are dual detectors, they were checked and operating. Fire extinguishers were charged and was serviced on 8/2/2023. Emergency disaster drills are conducted quarterly, last drill completed on 9/01/23. Staff and residents were interviewed.

There was outdoor seating for the residents. Outdoor area was clean and free of obstruction.

An exit interview was conducted, and a copy of this report was provided to AD1 whose signature confirms receipt.



LPA requested the following updated forms faxed to CCLD by 10/20/23: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Miriam Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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