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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208987
Report Date: 10/27/2022
Date Signed: 10/27/2022 01:26:50 PM

Document Has Been Signed on 10/27/2022 01:26 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:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jason Gavilan, DesigneeTIME COMPLETED:
01:30 PM
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On 10/27/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Designee Jason Gavilan. LPA was grant entry into the facility. LPA requested to meet with Administrator. Caroline Alacar, Administrator was called and stated unable to attend meeting. Administrator authorized Designee to receive and sign report. LPA conduct tour with Designee. No residents were present during the inspection.

Upon entry facility staff was observed with 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. COVID-19 and cough etiquette postings observed in facility.

LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in laundry room. LPA observed 30 day PPE supplies. LPA observed fire extinguisher served date: 07/05/22.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed four single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hand washing posting and trash bin with lid was observed in bathrooms. 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: 11/02/22. The following updated forms were requested: Lic 9282, and current liability insurance. LPA received copies of Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610E, Lic 9020, control of property, admission agreement policies and procedures. A copy of this report was provided to the Designee.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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