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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209244
Report Date: 07/26/2022
Date Signed: 07/26/2022 10:26:49 AM

Document Has Been Signed on 07/26/2022 10:26 AM - 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:FRESNO GUEST HOME #17FACILITY NUMBER:
107209244
ADMINISTRATOR:KUTNERIAN, GEORGEFACILITY TYPE:
740
ADDRESS:2568 E MENLO AVETELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 0DATE:
07/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Angela Kutnerian, Licensee Representative, Arielle Ballard, Asset Manager and JayCee Sanderson, Administrator CoordinatorTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Lady Cabrera conducted a Pre-licensing visit. LPA identified herself and discussed the purpose of the visit. LPA conducted the inspection with Angela Kutnerian, Licensee Representative, Arielle Ballard, Asset Manager and JayCee Sanderson, Administrator Coordinator using the Inspection Tool. A tour inside and outside the facility was conducted.

Common rooms have adequate furnishings and lighting. All client’s bedrooms have all the required furnishings (bed and dresser) and adequate lighting. Mattresses were in good condition. All rooms will be private. Home is fire cleared for five non-ambulatory elderly residents and one bedridden resident. LPA observed a supply of extra bed linens and personal hygiene and grooming products. Bathrooms were properly equipped, and trash cans had a fitting lid.

Hot water temperature was observed to be 118 degrees F. Kitchen observed to have dishes, plates, utensils. Sharps/knives and medications are locked in the kitchen. Cleaning supplies are stored. First aid kit contains all the required items. Fire extinguisher is present and was serviced in March 3, 2022. Smoke detectors and carbon monoxide were operating properly.



Outside of the facility toured. Exits open free of obstruction. Gate is self-latching. No outside hazards were observed.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: FRESNO GUEST HOME #17
FACILITY NUMBER: 107209244
VISIT DATE: 07/26/2022
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All required postings are posted. Facility phone number will be (559) 434-1839.

Component III conducted during pre-licensing inspection.

LPA have found that applicant has met all pre licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

Pre-Licensing is complete and this facility has no deficiencies.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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