<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206577
Report Date: 05/13/2022
Date Signed: 05/13/2022 12:11:03 PM

Document Has Been Signed on 05/13/2022 12:11 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: 3DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Fe DomingoTIME COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/13/22, LPA Medina conducted an unannounced Annual Required Infection Control Inspection. LPA met by Licensee/Administrator, Fe Domingo to conduct facility tour and inspection. All COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point, all staff and visitors enter through front door.

Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to resident and visitors. Social distancing is maintained in the common and dining areas. Resident bedrooms toured, resident bedrooms have a minimum of 6 feet between beds. Fire extinguisher present and has a service date of 04/14/2022, smoke detectors observed to be operational during inspection. Water temperature measured at 108 degrees F.

LPA checked residents’ medications and observed a 30-day supply. Food supply was observed to be sufficient for the residents in care. Facility staff was observed with mask on.

Licensee to submit updated LIC 500, LIC 610, and LIC 9020 to Fresno CCL office no later than 5/27/2022.

No deficiencies were observed. Exit interview was conducted. A copy of report was given to Administrator for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1