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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206858
Report Date: 09/14/2022
Date Signed: 09/14/2022 01:25:54 PM

Document Has Been Signed on 09/14/2022 01:25 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 CARE 3FACILITY NUMBER:
107206858
ADMINISTRATOR:DAVID C MURCHISONFACILITY TYPE:
740
ADDRESS:2822 CALIMYRNA AVETELEPHONE:
(559) 213-7251
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator Colin MurchisonTIME COMPLETED:
01:00 PM
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On 9/14/22, Licensing Program Analysts (LPA) M. Yang and B. Miranda arrived unannounced to conduct an Annual Inspection - Infection Control. LPAs introduced self, stated the purpose of the visit, and requested to meet with administrator. LPAs met with Gillian Ponce, Caregiver. Administrator Colin Murchison was called and arrived shortly and conduct tour with LPA. All six 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.

Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked under kitchen sink and in garage. LPAs checked residents’ locked medications. LPAs observed fire extinguisher served date: 02/08/22. LPAs observed small amount of PPE supplies in facility. 30 days PPE supplies storage in a central location.

All resident’s room toured and observed to be adequately furnished and lit. LPAs observed 6 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks.

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 resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 9/20/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 808, Lic 9282, Administrator certificate and current liability insurance. Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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