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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209490
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:18:26 PM

Document Has Been Signed on 08/26/2024 04:18 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:FRESNO GUEST HOME #23FACILITY NUMBER:
107209490
ADMINISTRATOR/
DIRECTOR:
LONG, TERESAFACILITY TYPE:
740
ADDRESS:2786 E FREMONT AVENUETELEPHONE:
(559) 434-1839
CITY:FRESNCOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 0DATE:
08/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Teresa LongTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Daiquiri Boyd arrived at the facility to conduct a Pre-Licensing Inspection. LPA met with Administrator (AD) Teresa Long.

LPA began the tour by entering through the front door of the 6 bedroom - 5 bathroom home. Common living spaces have new, clean furniture and lighting. Flooring is intact throughout the home. Smoke and Carbon Monoxide detectors were tested and found to be in working order. The Fire Extinguisher was serviced 8/5/2024 by Guardian Safety and Supply. LPA observed a supply of extra bed linens, towels, and personal hygiene and grooming products. Resident rooms are found to be in good repair and contained required furnishings, and lighting. The resident bathrooms are clean, in good repair with faucets delivering hot water at 105.4 degrees.

The kitchen was observed to have a supply of dishes, plates, utensils and cooking items. Food storage areas are clear and appropriate for food preparation. Cleaning supplies, chemicals, and sharps/knives are locked as required. Appliances were found to be in working order. LPA observed the required food supply. Resident medications will be stored in a designated locking kitchen pantry closet. The First Aid kit is new and contains all required items. Doors and passageways are unobstructed throughout the inside and outside of the home.

Outside of the facility was toured. There is a covered seating area and a self-closing gate with system alarm, found to be working properly. LPA confirmed the facility phone number is activated by calling (559) 701-0150. Required postings are placed.

LPA, together with AD, pulled up the CCLD website and reviewed where to find documents, forms, and information.

See LIC809C for continuation of this report
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: FRESNO GUEST HOME #23
FACILITY NUMBER: 107209490
VISIT DATE: 08/26/2024
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Emergency Disaster and Infection Control Plans were reviewed and COMP III was conducted during this 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 a copy of this report was left with AD, whose signature confirms receipt.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC809 (FAS) - (06/04)
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