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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209483
Report Date: 01/06/2025
Date Signed: 01/07/2025 09:00:34 AM

Document Has Been Signed on 01/07/2025 09:00 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CLOSE TO HOME RESIDENTIAL CAREFACILITY NUMBER:
107209483
ADMINISTRATOR/
DIRECTOR:
AMBRIZ, EMILYFACILITY TYPE:
740
ADDRESS:5852 E BURNS AVETELEPHONE:
(559) 708-8822
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 4DATE:
01/06/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Janay Gonzales, Caregiver TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced Post Licensing Inspection on this date. LPA was met by care giver Janay Gonzales. Administrator was away from the home. Residents were observed at the facility. Positive interactions between staff and residents were observed.

The CARE tool was not accessible so was not utilized in today's inspection.

Facility was observed at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. The tour started in the residents' rooms. Residents bedrooms were observed to be adequately furnished with bed, dresser, chair and adequate lightning. Bathrooms were properly equipped with non-skid mats and securely fastened grab bars. Hot water thermometer was not working so water temperature was not tested. Common areas were properly furnished and well-lit throughout. The built in pool in back yard is appropriately fenced. Back yard was clean and exit fences are self closing and operating properly. Fire extinguisher was observed with a current date of service. Carbon monoxide and smoke detectors observed to be operational. Cleaning supplies and chemicals were observed in the locked cabinets in the garage and overflow food is stored in 2 extra refrigerators located in garage as well. First Aid Kit was checked and observed to have the required supplies. The tour concluded in the kitchen. A sufficient supply of perishable and non-perishable food were observed. Medications are kept in a locked cabinet off the kitchen. LPA reviewed medications, and MARS and observed to be in compliance.

The following post licensing topics will be discussed at a later visit: *Mandatory Reporting of Abuse, *In-Service Training, *Medication Procedures, *Personal Rights, and *Records Reviewed. At today's visit LPA left handout for Technical Services Program (TSP) as well as instructions for submitting IR's.

No deficiencies were observed. Exit Interview conducted. A copy of this report will be provided to the Administrator via email. Signature of Caregiver was authorized by Administrator
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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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