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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206803
Report Date: 09/15/2021
Date Signed: 09/15/2021 01:44:21 PM

Document Has Been Signed on 09/15/2021 01:44 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:STEPHEN HOUSEFACILITY NUMBER:
107206803
ADMINISTRATOR:SUNDARI SUSAN KENDAKURFACILITY TYPE:
740
ADDRESS:1824 DONNER AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:SUNDARI SUSAN KENDAKUR, ADMINISTRATORTIME COMPLETED:
12:45 PM
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On 09/15/2021, Licensing Program Analysts (LPA) M. Yang and A. Walton arrived unannounced at the above facility. LPAs introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPAs met with Administrator Sundari Susan Kendakur who arrived a short time later. LPAs conduct tour with Administrator. All four residents were present during the tour. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Fire extinguisher observed to be last serviced 05/7/2021. Social distancing is maintained in the common and dining areas. All bathrooms are observed with trash cans with lid and securely fastened grab bars. There are non-skid surfaces in the bathrooms. LPAs observed no hand washing posting in 2 of the 3-bathroom sinks. Bedrooms are single occupant.

LPAs checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and there appeared to be an adequate supply. Facility staff was observed with mask on. Staff records were reviewed for good health and infection control training. All residents have updated emergency contact information. Facility has not submitted LIC 808 Mitigation plan to Community Care Licensing.

No deficiencies issued during this inspection.

Exit interview was conducted. Please submit the LIC 808 to Fresno CCL by: 09/21/21.


Please submit the following forms/information to Fresno CCL by: 09/28/21: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities for The Elderly, LIC 9020 Register of Facility Clients/Residents, updated Liability Insurance, current property lease, LIC 309 Administrative Organization, current Administrator Certification, LIC 808 Covid-10 Mitigation Plan. Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this email. Report signed on-site.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2021
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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