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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209220
Report Date: 04/14/2022
Date Signed: 04/14/2022 11:40:43 AM

Document Has Been Signed on 04/14/2022 11:40 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:JEFFRIES HOME RCFEFACILITY NUMBER:
547209220
ADMINISTRATOR:SEARCY, KIMFACILITY TYPE:
740
ADDRESS:2545 W WHITE CHAPEL AVETELEPHONE:
(559) 359-3671
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Jennifer JeffriesTIME COMPLETED:
11:49 AM
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On 04/14/2022, Licensing Program Analyst (LPA) M. Medina conducted an announced Pre-Licensing and Component III Inspection. LPA met with Licensee Jennifer Jeffries. There are currently 6 residents in placement, facility is currently licensed as Adult Residential.

The facility is a 7 bedroom and 3 bathrooms home and fire clearance were granted for 4 ambulatory and 2 non-ambulatory for a total capacity of 6. There were no residents present during this inspection. Common areas were observed to have adequate seating and lighting available. Bedrooms were observed to have the required furnishings. Hot water temperature 108 degree F.

Kitchen was toured and observed to have dishes, plates, and utensils. Knives will be kept locked and secure in the kitchen pantry. Medications will be locked in lock box in the pantry. First aid kit was observed and contained all required items. Cleaning supplies and chemicals observed to be locked in laundry room. A fire extinguisher was observed and had a service date of 01/19/22. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Outside of facility toured. Exits were open and free of obstructions.

Component III was conducted during today's pre-licensing visit.

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: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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