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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208987
Report Date: 10/24/2024
Date Signed: 10/31/2024 11:42:10 PM

Document Has Been Signed on 10/31/2024 11:42 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/
DIRECTOR:
ALACAR. CAROLINEFACILITY TYPE:
740
ADDRESS:4640 E KAVILANDTELEPHONE:
(559) 515-6120
CITY:FRESNOSTATE: CAZIP CODE:
93725
CAPACITY: 4CENSUS: 4DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator (Admin) Caroline Alacar; Program Manager (PM) Jason Gavilan; Lead Staff (LS) Dina RosarioTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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An Annual visit was conducted by Licensing Program Analyst (LPA) K. McClurg. LPA met with Administrator (Admin) Caroline Alacar, introduced self, provided business card, stated purpose of visit & was allowed entry. LPA also met Program Manager (PM) Jason Gavilan & Lead Staff (LS) Dina Rosario during visit. Facility has a granted Hospice care waiver for 3 residents. None of residents are currently receiving Hospice care services. This facility has no open bodies of water such as pools, spa, fountains, etc. Facility has wood burning fire place that is not used & access to is limited.

Physical Plant toured. Kitchen appeared to be clean & organized. Knives & cleaning products in separate locked areas making inaccessible to residents. Sufficient supply of perishable & nonperishable food on the premises. Dining/living room sufficiently furnished. Furnishings appeared to be in good repair. Sufficient lighting. Resident bedrooms appeared to be sufficiently furnished with items in good repair & adequate lighting. Linens on beds & additional supplies available as needed. Resident bathrooms appeared & smelled to be clean with no unpleasant odors. Fixtures operational. Grab bars in toilet & shower areas. Sinks in resident bathrooms are on sensors & delivers mix of hot & cool water. Hot water measured at kitchen faucet measuring 108 degrees F. Interior passageways & exits observed to be clear with no obstructions, including exit door in each resident bedroom. Smoke & carbon dioxide detectors operational. Fire extinguisher service date: 8/9/24.

Outside area clear of debris. Backyard sufficiently maintained. Sufficient seating in good repair. Passageway to exit gate clear & unobstructed. Garage access off of front of facility & kept locked for security purposes. Garage area with inaccessible storage for cleansers, etc. that may pose a risk to clients.

Medications observed to be inaccessible to clients & organized. Medication Administration Records (MARs) & Centrally Stored Medication & Destruction Records (CSMDRs) documentation completed & maintained. Resident files maintained. Staff files maintained. Admin Residential Care Facility for the Elderly (RCFE) Administrator Certificate #7013451740 expires: 04/18/2025 per 10/24/24 verification through Community Care Licensing Division (CCLD) website: Active Administrator Certificate Holders.

Exit interview conduced with Admin, PM, & LS. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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