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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107207121
Report Date: 11/12/2021
Date Signed: 11/12/2021 02:28:42 PM

Document Has Been Signed on 11/12/2021 02:28 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:NINA'S HOMEFACILITY NUMBER:
107207121
ADMINISTRATOR:RODRIGUEZ, LETICIAFACILITY TYPE:
740
ADDRESS:6540 N. BRIARWOODTELEPHONE:
(559) 253-3024
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 6DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Leticia Rodriguez - AdministratorTIME COMPLETED:
01:00 PM
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On 11/12/2021, Licensing Program Analyst's(LPA's) D. Ayers and K. Kaur arrived at the facility unannounced to conduct a required annual inspection. LPA's met with administrator Leticia Rodriguez and announced the purpose of the visit.

LPA's toured the facility inside and outside. The facility was adequately furnished and lit throughout. All passageways and exits were clear and free from obstruction. The facility had multiple fire extinguishers with receipts dated 10/28/2021. All smoke and carbon monoxide detectors were observed to be functional. The last fire drill was conducted 10/1/2021. LPA's observed a two-day supply of perishable food stuffs and a seven-day supply of nonperishable food stuffs which were stored properly in the facility. The facility had a refrigerator in the garage with extra food stuffs. Medications were secured in a locked closet and appeared to be administered properly. LPA's toured resident bedrooms and bathrooms. Resident bedrooms were adequately furnished, and bathrooms have required secure grab bars and nonskid mats. Facility emergency/disaster plan was reviewed. LPA's reviewed infection control guidelines and best practices with Administrator.

No deficiencies cited during the inspection. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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