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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208833
Report Date: 04/12/2022
Date Signed: 04/12/2022 11:18:57 AM

Document Has Been Signed on 04/12/2022 11:18 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:TIMMERMAN D AND M FAMILY CARE HOMEFACILITY NUMBER:
547208833
ADMINISTRATOR:TIMMERMAN, DARRENFACILITY TYPE:
740
ADDRESS:22547 AVE 178TELEPHONE:
(559) 310-6202
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 5DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Monica TimmermanTIME COMPLETED:
11:24 AM
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On 4/12/2022, Licensing Program Analyst (LPA) M. Medina conducted an Annual Required Infection Control Inspection. LPA Medina met by Licensee, Monica Timmerman and stated the purpose of the facility visit. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Monica Timmerman, Administrator Certificate #6045828740, expires 12/4/2023.

Tour of the facility conducted. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. 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. LPA observed residents participating in day program activities during inspection and practicing social distancing.

LPAs checked residents’ medications and observed a 30-day supply. LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available. Cleaning and PPE supplies were checked. Resident’s files have updated emergency contact information. Fire extinguisher present with a service date of 10/14/2021. LPA observed carbon monoxide detectors and smoke detectors to be operational during today's inspection.

Outside of facility toured. No hazards observed. Facility pool is surrounded with a locked and secured 6 foot fence.

No deficiencies were observed. Exit interview was conducted. Facility report signed on site. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed.

No deficiencies issued during inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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