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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206577
Report Date: 06/11/2021
Date Signed: 06/14/2021 12:38:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/14/2021 12:38 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:DOMINGO HOME, THEFACILITY NUMBER:
547206577
ADMINISTRATOR:DOMINGO, WALTER OR FEFACILITY TYPE:
740
ADDRESS:2069 LINDA VISTATELEPHONE:
(559) 784-2762
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Fe DomingoTIME COMPLETED:
11:21 AM
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Licensing Program Analyst (LPA) M. Medina conducted an Annual Inspection on this date. LPA was met by Licensee, Fe Domingo and stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Resident bedrooms toured, resident bedrooms have a minimum of 6 feet between beds.

Fire extinguisher present and has a service date of 11/12/2020. Carbon monoxide detector present and observed to be operational during today's inspection. Hot water measured at 112 degrees F.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Resident’s files have updated emergency contact information. Mitigation plan received and approved by Department on 3/26/2021. Fe Domingo also serves as facility Administrator certification #6015208740, expires 7/15/2022. First/CPR expires 5/28/2022.

No deficiencies were observed. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2021
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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