100400070-6-26-2024-24-AS-LPAT-D49RC7-20240412125350

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 100400070
Report Date: 03/25/2024
Date Signed: 06/26/2024 06:39:41 AM

Document Has Been Signed on 06/26/2024 06:39 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	CALIFORNIA ARMENIAN HOME		FACILITY NUMBER:	100400070
ADMINISTRATOR:	PAUL ROCHA		FACILITY TYPE:	741
ADDRESS:	6720 E KINGS CANYON RD		TELEPHONE:	(559) 251-8414
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	392	CENSUS: 234	DATE:	03/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Paul Rocha, Administrator		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts L. Padgett and Katie Brown (LPA), conducted an unannounced annual visit to the facility and met with Administrator, Paul Rocha (AD). LPA stated the purpose of the visit and was accompanied by AD while conducting the inspection of the facility. This facility has independent villas, a main building with independent residents on the first and third floor and Assisted Living on the second floor. Memory Care is in its own building. LPA toured the main building with AD. LPA observed ambient thermostat to be at 73 degrees F. On the first floor, LPA toured the Harvest Café. Menu is displayed on TV screen. This café serves grab and go items. Area observed to be in good condition. LPA observed Fire Side lounge area to have seating area, faux fireplace with does not emit heat and board games. This floor also has fitness room with exercise machines and free weights. Kitchen storage observed to have supply of paper goods, cleaning supplies/disinfectants and hand soap. LPA checked water in Guest/Resident bathroom, temperature was found to be 106.9. LPA observed laundry rooms with keyed entry to have working washers and dryers and cleaning supplies. In The Grape Vine kitchen LPA observed that the kitchen was well maintained, with working lights and well maintained appliances. The kitchen counters and sink are free from debris, well maintained and clean. LPA observed that refrigerator was kept at a 40 degree F, and the freezer at 2 degrees F. LPA observed a 2 day perishable food supply. The kitchen pantry was clean, organized, and had 7 days of non-perishable food. No expired food was observed. A 2nd floor kitchen was toured. Two refrigerators observed, one is kept at 38 degrees F and the other 43 degrees F.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CALIFORNIA ARMENIAN HOME	FACILITY NUMBER: 100400070
	VISIT DATE: 03/25/2024

NARRATIVE

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LPA observed the dining rooms on each floor. All are well lit with adequate seating. There are TV screens in the hallways which display the weather, activity calendar and events.

LPA observed multiple seating and activity areas that contains games and puzzles, TV’s, coffee and ice water, bowls of fresh fruits (apples, bananas and oranges). LPA observed Activity room with piano, keyboard, tables, chairs and board games.

LPA observed the hallways leading to the resident rooms, smoke detectors, and carbon monoxide are installed. A fire extinguishers are mounted on the walls and were inspected on 5/1/2023 with the correct pressure gauge as indicated on the meter. The smoke alarm and carbon monoxide detectors are tested monthly by MS Fire Protection, last inspection was on 3/12/2024.

LPA observed room #206 is not shared, has a private bathroom with covered trash bin, shelves for toiletries, grab bars, non-skid flooring. The water temperature measured at 111.6 degrees F. The room is well lit, a dresser, reading lamp, the furniture is in good condition, the linens are in good condition. Room has kitchenette The bedroom has a closet, dresser and night stand.

LPA observed that Room #257 is not shared, has a private bathroom with covered trash bin, shelves for toiletries, grab bars, non-skid flooring. The water temperature measured at 110.1 degrees F. The bedroom is well lit, a dresser, reading lamp, the furniture is in good condition, the linens are in good condition. The bedroom has a closet, dresser and night stand.

LPA observed that bedroom #260 is not shared, has a private bathroom with covered trash bin, shelves for toiletries, grab bars, non-skid flooring. The water temperature measured at 110.8 degrees F. The rooms are well lit with required furniture in good condition.

LPA with AD inspected exterior areas. LPA, observed the landscaping is well maintained, trees, bushes and grass in good condition. Patio furniture is clean and ready for use. The exterior walkways are free from obstructions and debris.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CALIFORNIA ARMENIAN HOME	FACILITY NUMBER: 100400070
	VISIT DATE: 03/25/2024

NARRATIVE

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LPA toured the memory care building with AD. Ambient temperature was 75 degrees F. LPA toured 4 resident rooms.

Room 25 had required furniture in good condition. Fall prevention measures are in place. LPA observed resident in bed watching TV.

Room 2 has a hospital bed with ½ rails, chair, dresser, TV. Resident was not in the room.

Room 8 is a single room with required furnishing in good condition. LPA observed resident to be in good spirits. Water temperature was checked and observed to be 108.3 degrees F.

Room #24 had required furnishing in good condition, resident was sleeping.

Medication room toured. Medications are centrally stored. No insulin or refrigerated medications.

Laundry room observed to have 3 washers, 2 dryers, cleaning chemicals stored in cabinets. Laundry room is kept locked with key entry.

LPA observed prep kitchen in open area, nothing is stored in cabinets. Refrigerator observed to be 33 degrees F.

LPA observed 6 residents in the activity area engaged in conversation.

LPA observed the kitchen to be in good condition with well maintained appliances. LPA observed Dry goods and canned items, knives on magnet block. Refrigerator was 36 degrees F, Freezer 0 degrees F.

LPA reviewed residents and staff records, infection control plan was not provided for review.

LPA is requesting the following documents be submitted to the Fresno CCL office by 4/5/2024: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A)

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC809 (FAS) - (06/04)

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