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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209171
Report Date: 10/12/2022
Date Signed: 10/12/2022 11:14:07 AM

Document Has Been Signed on 10/12/2022 11:14 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:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Mary Ellen Gurrola
Andrea Duran		TIME COMPLETED:
11:24 AM
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On 10/12/2022, Licensing Program Analyst (LPA) M. Medina conducted an Annual Required Infection Control Inspection. LPA Medina by Licensees Mary Ellen Gurrola and Andrea Duran.

COVID-19 guidelines are in place. Staff observed to be wearing masks. Visitor log-in/temperature check observed upon entry. All visitors and staff enter through front door.

Facility toured, facility observed to be clean and odor free. All common areas observed to have adequate seating and lighting. Resident bedrooms toured, 2 rooms are private, one shared room observed to have a minimum of 6 feet between beds. Kitchen toured, facility has a 2-day supply of perishable and a 7-day supply of non-perishable food available. Medication observed to be locked and secured in kitchen cabinet

Fire extinguisher present and has a service date of 3/28/2022. Carbon monoxide detector and smoke detectors present and observed operational during today's inspection.

Andrea Duran serves as facility Administrator certification #6007971740, expires 5/4/2023.

LPA received copy of Infection Control Plan Addendum to include Monkey Pox, Administrator Certificate, and surety bond during facility inspection.

No deficiencies were observed. Exit interview was conducted. Report signed during inspection and a copy left for facility file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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