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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209251
Report Date: 02/07/2023
Date Signed: 02/07/2023 11:09:38 AM

Document Has Been Signed on 02/07/2023 11:09 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:HERITAGE CARE HOMEFACILITY NUMBER:
107209251
ADMINISTRATOR:KUMAR, ARUNFACILITY TYPE:
740
ADDRESS:167 W GOSHEN AVETELEPHONE:
(559) 473-8988
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 0DATE:
02/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Licensee 1 (L1) Arun Kumar and Licensee 2 (L2) Manprit Singh TIME COMPLETED:
11:15 AM
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On 02/07/23, Licensing Program Analyst (LPA) M. Yang arrived to the facility announced to conduct the Pre-licensing visit. LPA was greeted by Licensee 1 (L1) Arun Kumar who granted LPA entry into the facility. Licensee 2 (L2) Manprit Singh arrived shortly.

The facility is a 6 bedroom and 3 bathroom home and fire clearance was granted for 3 Non-Ambulatory and 3 Bedridden for a total capacity of 6. There are no residents present during this inspection.

LPA toured the facility with L1 and L2. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available. Bedrooms were observed to have the required furnishing and are ready for occupancy. Refrigerator temperature maintained at 35 degrees F and freezer temperature at 0 degree F. Hot water temperature ranged between 105.1 to 105.2 degrees F.

LPA observed an extra supply of bed linens and personal hygiene products. Kitchen was toured and observed to have dishes, plates, and utensils. Knives were kept locked and secure in the kitchen drawer. Medications will be locked in hall closet. First aid kit was observed and contained all required items. Cleaning supplies and chemicals observed to be locked under kitchen sink and in laundry room. Fire extinguisher was observed and had a service date of 02/28/22.

Outside of the facility toured. The facility pool is gated and locked inaccessible to residents. Exits open free of obstruction. No outside hazards were observed. Facility has seating area for residents. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Facility phone number is (559) 765-0893.

Component III was conducted during today's pre-licensing visit.

I 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.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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