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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209269
Report Date: 10/20/2022
Date Signed: 10/20/2022 11:31:27 AM

Document Has Been Signed on 10/20/2022 11:31 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:HALEYS HOME CARE LLCFACILITY NUMBER:
547209269
ADMINISTRATOR:ARRIAGA, PATRICIAFACILITY TYPE:
740
ADDRESS:1966 DATE AVETELEPHONE:
(559) 854-0523
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 0DATE:
10/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Patricia ArriagaTIME COMPLETED:
11:40 AM
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On 10/20/22, Licensing Program Analyst (LPA) M. Medina 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 Licensee Patricia Arriaga. LPA toured the facility with Licensee. The facility is 5 bedrooms and 2 bathrooms home. Fire clearance was granted for 6 ambulatory residents.

Common areas were furnished and had adequate seating and lighting available. All bedrooms were observed to have required furnishings. Kitchen was toured and observed to have dishes, plate, and utensils. Facility has 7-day supply of non-perishable food available as of date of inspection. Knives were observed to be locked and secure in kitchen drawer. Medications will be kept in locked closet. Hot water temperature measured at 120 degrees F. First aid kit was observed. Cleaning supplies and chemicals were observed to be in a locked cabinet in the garage. Outside of facility toured. Exits were open and free of obstructions. Fire extinguisher present with a service date of 8/30/22. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection.

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

The following items must be completed prior to applicant meeting all pre-licensing requirements 1) First Aid kit missing First Aid Manual 2) Fire exit gate is not self-latching and 3) Facility has no containers for trash pick up from the city.

LPA will conduct follow up inspection visit when corrections have been completed. Exit interview conducted and a copy of report provided for facility records.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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