<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206785
Report Date: 03/16/2022
Date Signed: 03/21/2022 01:34:27 PM

Document Has Been Signed on 03/21/2022 01:34 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:PETERSON RESIDENTIALFACILITY NUMBER:
107206785
ADMINISTRATOR:O'DONNELL, CAROLFACILITY TYPE:
740
ADDRESS:455 S. KONATELEPHONE:
(559) 492-2189
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 4DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Carol O'DonnellTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/16/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Administrator Carol O'Donnell

Visitor log-in, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point.
Hand washing and other various Covid-19 related signs were observed in the common areas.

Facility tour conducted with Administrator. The facility was observed at a comfortable temperature, clean, and in good repair. No obstruction or fire clearance hazards were observed. LPA toured 2 private bedrooms with adequate furnishings for four residents. Bathroom was properly equipped with non-slip mat and grab bar. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA checked residents' medication and observed a 30-day supply, which are kept in a locked closet in the kitchen. Chemicals, cleaning supplies were observed to be locked in the Laundry room. Resident’s files have updated emergency contact information. Staff files were reviewed for good health.

No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 3/23/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC
309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel
Report (LIC610E), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. As a COVID-19 precautionary measure, a copy of this
report will be provided via email. Report signed on-site by Administrator.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1