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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209195
Report Date: 01/19/2022
Date Signed: 01/20/2022 03:46:06 PM

Document Has Been Signed on 01/20/2022 03:46 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:WIGGINS HOME 4FACILITY NUMBER:
547209195
ADMINISTRATOR:BOYD, ELYSIAFACILITY TYPE:
740
ADDRESS:2102 WEST ORANGE AVENUETELEPHONE:
(559) 350-0141
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 4DATE:
01/19/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elysia (Shelly) Boyd, LicenseeTIME COMPLETED:
10:45 AM
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On 01/19/2022, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Elysia (Shelly) Boyd, Licensee.

The facility is 4 bedroom and 2-bathroom home. Fire clearance was granted for 2 Non-Ambulatory and 2 Ambulatory for total of 6 capacity. There are 4 residents present during this inspection.

LPA toured the facility with Licensee. The facility was adequately furnished, well-lit, and at a comfortable temperature. Kitchen was toured and observed to have dishes, plate, and utensils. LPA observed a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. Knives were observed to be locked and secure in the kitchen drawer. Medications were kept locked and inaccessible to residents in care. First aid kit was observed and contained all required items. Cleaning supplies and chemicals were observed to be in a locked cabinet in the garage and under kitchen sink. Bedrooms were observed to have required furnishings. Hot water measured at 110 degrees F in all bathrooms. LPA observed an extra supply of bed linens and personal hygiene products.

Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching. A fire extinguisher was observed and has a service date of 07/01/2021. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. Last fire drill conducted on 01/16/2022. Resident records were reviewed. LPA observed all residents’ Admission Agreements, Physician Reports, and update emergency contact information. All Staff records were reviewed for good health and infection control training. All staff have a criminal record clearance.

No deficiencies were cited during the inspection.

I have found that the 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: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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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