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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208831
Report Date: 10/06/2021
Date Signed: 10/06/2021 03:28:46 PM

Document Has Been Signed on 10/06/2021 03:28 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:GAITHER'S FAMILY HOMEFACILITY NUMBER:
547208831
ADMINISTRATOR:GAITHER, HENRIETTAFACILITY TYPE:
740
ADDRESS:1441 SAN LUCIA AVENUETELEPHONE:
(559) 920-3939
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 4DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Kristie RackleyTIME COMPLETED:
03:42 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
Licensing Program Analyst (LPA) M. Medina arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Program Manager, Kristie Rackley and stated purpose of the visit. LPA completed the COVID Contact questionnaire prior to entrance into the facility. LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors.

Mitigation plan has been submitted to Community Care Licensing. Infection control procedures described in the plan and observed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), visitation policy, quarantine/isolation procedures, and surveillance testing procedures are all in place. Infection control lead is Kristie Rackley. Staff are continuously provided training and updates related to COVID-19.

LPA toured the facility, required postings include hand washing, coughing etiquette and physical distancing were observed in the facility. Staff were all observed wearing face coverings. LPA observed a 30 day supply of PPE and resident medications. Sinks are well stocked with paper towels and liquid soap for hand washing.

Licensee to submit the following documents to Fresno CCL office by 10/15/21: Copy of Administrator Certificate, first aid card, LIC 500, LIC 610, and LIC 9020.

LPA observed the required infection control practices to be in compliance. No deficiencies were observed. Exit interview was conducted and Program Manager 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: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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