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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209171
Report Date: 09/30/2021
Date Signed: 10/01/2021 09:06:55 AM

Document Has Been Signed on 10/01/2021 09:06 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:GURROLA CARE HOME #3FACILITY NUMBER:
547209171
ADMINISTRATOR:GURROLA, MARY ELLENFACILITY TYPE:
740
ADDRESS:287 TEAPOT DOME #BTELEPHONE:
(559) 719-7484
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 4DATE:
09/30/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Andrea DuranTIME COMPLETED:
11:41 AM
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Licensing Program Analysts (LPA) M. Medina conducted an announced Pre-licensing inspection on this date. LPA Medina met with Licensee, Andrea Duran. This address is currently licensed for 4 residents. All residents present during today's inspection.

LPA toured facility. Common rooms have adequate furnishings and lighting. All of the resident bedrooms required furnishings and adequate lighting. LPA observed a supply of extra bed linens and personal hygiene and grooming products. Kitchen observed to have dishes, plates, utensils. Food supply is adequate for the residents in care. Medications are stored and locked in kitchen cabinet.

Hot water measured at 114 degrees F. Fire extinguisher is present with a service date of 4/29/2021. Facility is equipped with a pull station, carbon monoxide detector and smoke alarms are present and observed to be operational during today's pre-licensing inspection. First Aid kit and manual are present with regulation items.

Outside of the facility toured. All fire exits open free of obstruction.

All required postings are posted. Facility phone number will be (559) 793-1354 .

I have found that 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: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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