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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206601
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:26:05 PM

Document Has Been Signed on 05/10/2022 02:26 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:A PLACE CALLED HOME RESIDENTIAL CAREFACILITY NUMBER:
107206601
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2827 CALIMYRNA AVETELEPHONE:
(559) 322-4432
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 5DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Administrator Collin Murchison TIME COMPLETED:
02:45 PM
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On 05/10/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Micah Lermen, Caregiver. Administrator Collin Murchison was called and arrived shortly and conduct tour with LPA. All five residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed. LPA observed fire extinguisher served date: 02/08/22.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed five single occupant rooms and one vacant bedroom. All bathrooms are observed with securely fastened grab bars and non-skid mat. LPA observed bathrooms trash bin with lid. Hand washing posting observed by bathroom sinks.

LPA checked residents’ locked medications. LPA observed small amount of PPE supplies in facility. 30 days PPE supplies storage in a central location. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in laundry room and under kitchen sink.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. LPA received copies of current Administrator certificate, Lic 308, Lic 309, Lic 610E, Lic 808, Lic 9020, and current liability insurance. A copy of this report was provided to the Administrator.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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