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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208987
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:01:37 PM

Document Has Been Signed on 10/26/2021 03:01 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:CHERRY AND MICHAEL'S HOMEFACILITY NUMBER:
107208987
ADMINISTRATOR:ALACAR. CAROLINEFACILITY TYPE:
740
ADDRESS:4640 E. KAVILANDTELEPHONE:
(559) 301-4720
CITY:FRESNOSTATE: CAZIP CODE:
93725
CAPACITY: 4CENSUS: 4DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Caroline Alacar, Administrator TIME COMPLETED:
02:15 PM
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On 10/26/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced at the above facility. LPA introduced self, stated the purpose of the visit, and met with Administrator Caroline Alacar. Facility staff was observed with mask on. LPA conduct tour with Administrator. Two 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. Social distancing and cough etiquette postings observed in facility. Social distancing is maintained in the common and dining areas. Food supply was checked and there appeared to be an adequate supply. LPA checked residents’ locked medications and observed a 30-day PPE supplies.

LPA toured 4 single occupant resident room furnished and adequately lit. All bathrooms are observed with trash cans with lid and securely fastened grab bars. Bathrooms have non-skid mat. Hand washing posting observed in 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 residents have updated emergency contact information. Fire extinguisher observed to be last serviced 04/22/2021.

No deficiencies issued during this inspection.

The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610E, Lic 9020, and current lease. Please submit the above forms to Fresno CCL by: 11/01/21. LPA received copy of Administrator Certificate during facility inspection.

Exit Interview conducted. Administrator was informed that as COVID-19 precautionary measure, this report was provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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