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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206803
Report Date: 08/19/2022
Date Signed: 08/19/2022 01:56:51 PM

Document Has Been Signed on 08/19/2022 01:56 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: 5DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Administrator Sundari Susan Kendakur and Shannon Steele Care Coordinator TIME COMPLETED:
12:35 PM
NARRATIVE
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On 08/19/22 Licensing Program Analyst (LPA) M. Yang arrived unannounced at the above facility. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPA met with Marcos Garcia, caregiver. Administrator Sundari Susan Kendakur and Shannon Steele Care Coordinator (CC) was called and arrived shortly. LPA conduct tour with Administrator. Four residents were present during the tour.

Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility staff was observed with mask on. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Staff records were reviewed for good health and infection control training.

Food supply was checked and there appeared to be an adequate supply. LPA checked residents’ locked medications and observed a 30-day PPE supplies. Fire extinguisher observed served date 06/01/22. All bathrooms are observed with trash cans with lid and securely fastened grab bars. There are non-skid mat in the bathrooms. LPA observed hand washing posting in all bathroom sinks. All bedrooms are single occupant. Approximately at 11:46 AM, LPA, Administrator, and CC observed inside unlocked garage laundry detergent. The exterior tour was conducted. Side gate was self-closing and self-latching. All residents have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 8/26/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, and current liability insurance. LPA received copy of Lic 9282. A copy of this report and appeal rights was provided to Administrator via email. Signed report on file.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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Document Has Been Signed on 08/19/2022 01:56 PM - It Cannot Be Edited


Created By: Mai Yang On 08/19/2022 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: STEPHEN HOUSE
FACILITY NUMBER: 107206803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2022
Section Cited

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Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above when approximately at 11:46AM, LPA, Administrator, and CC observed two laundry detergent buckets stored in the garage unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022


LIC809 (FAS) - (06/04)
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