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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209467
Report Date: 08/29/2024
Date Signed: 08/30/2024 09:41:14 AM

Document Has Been Signed on 08/30/2024 09:41 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:WOLDEN FAMILY HOME #4, INC.FACILITY NUMBER:
157209467
ADMINISTRATOR/
DIRECTOR:
WOLDEN, CHERYLFACILITY TYPE:
740
ADDRESS:2039 5TH PLACETELEPHONE:
(559) 967-1833
CITY:DELANOSTATE: CAZIP CODE:
93215
CAPACITY: 4CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:38 PM
MET WITH:Administrator, Kyle Wolden
House Manager, Courtney Lopez
TIME VISIT/
INSPECTION COMPLETED:
09:24 PM
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Licensing Program Analyst (LPA) L. Salazar arrived at the facility for a scheduled Pre-licensing visit. LPA was greeted by Administrator Kyle Wolden and House Manager Courtney Lopez and allowed entry into the facility.

LPA toured the facility inside and outside. The facility was observed to be clean, free from clutter and was odor free. LPA observed 3 out of 3 residents present at the time of inspection. The common area rooms were observed to have adequate furnishings, window coverings and lighting. All resident bedrooms were observed to be private and have the required furniture, to include beds with good mattresses, night stand, chair and personal lighting. LPA observed an adequate supply of extra bed linens, towels and personal hygiene/ grooming items.

Bathrooms were observed to be properly equipped with trash cans. Hot water temperature was observed to be 108.6 degrees F. Medications are locked in a closet in the living room. Cleaning supplies are stored in a locked cabinet in the activity. First aid kit contains all the required items. Fire extinguisher is present and was serviced in November 28, 2023. Smoke detectors and carbon monoxide were operating properly. 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. Component III conducted during pre-licensing inspection. Pre-Licensing is complete. 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: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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