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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209348
Report Date: 08/01/2023
Date Signed: 08/01/2023 11:16:14 AM

Document Has Been Signed on 08/01/2023 11:16 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 #19FACILITY NUMBER:
107209348
ADMINISTRATOR:KUTNERIAN, ANGELICAFACILITY TYPE:
740
ADDRESS:2149 E MENLO AVETELEPHONE:
(559) 434-1839
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 0DATE:
08/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Angelica KutnerianTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct the Pre-Licensing Inspection. LPA met with Administrator (AD) Angelica Kutnerian. LPA began the tour by entering through the front door of the single-story 6 bedroom home.

Furniture and flooring in common areas was observed to be in good repair with adequate lighting throughout.
Resident bedrooms have the required furnishings, lighting and bed linens. Smoke and Carbon Monoxide detectors present and in working order. LPA observed supply of extra bed linens, towels, and personal hygiene/grooming products. Resident bathrooms were stocked with hand soap, paper towels and garbage cans with lids. Hot water temperature in resident bathroom measured at 115 degrees Fahrenheit.

The kitchen observed to have supply of dishes, cups, plates, utensils, pots and pans and cooking utensils in good repair. LPA observed a 7 day of non-perishable food supply. Counter tops and cabinets are clear and appropriate for food preparation. Knives, cleaning supplies and chemicals are stored and locked separate from food. A Washer and Dryer were observed in the laundry room with additional shelving. Chemicals will be stored in the laundry room. Appliances observed to be in working order and at maintained at proper temperature. Cameras are placed in common areas only.

Medications and resident files will be stored in a locked cabinet. The First aid kit contains all required items. Fire extinguishers are present dated 5/18/2023. Doors and passageways are unobstructed throughout the home. Required postings were placed in common areas.

See LIC809-C for continuation of this report
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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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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 #19
FACILITY NUMBER: 107209348
VISIT DATE: 08/01/2023
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Outside of the facility was toured. The home does not have a pool or bodies of water. Outdoor activity space with shaded area and seating were located on the covered backyard patio. A self-releasing gate was observed to be in working order.

Facility phone line was verified, the number is (559) 500-1055. Component III was conducted during the visit with AD.

The applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued. An exit interview was conducted and copy of this report was provided to Angelica Kutnerian.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC809 (FAS) - (06/04)
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