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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400070
Report Date: 03/08/2022
Date Signed: 03/08/2022 09:07:31 PM


Document Has Been Signed on 03/08/2022 09:07 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:CALIFORNIA ARMENIAN HOMEFACILITY NUMBER:
100400070
ADMINISTRATOR:PAUL ROCHAFACILITY TYPE:
741
ADDRESS:6720 E KINGS CANYON RDTELEPHONE:
(559) 251-8414
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:356CENSUS: 280DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator Paul Rocha TIME COMPLETED:
03:00 PM
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On 03/08/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Caregiver. Caregiver contacted Administrator Paul Rocha, who arrived shortly thereafter.

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility buildings have one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas.

Facility tour conducted with Administrator. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. Facility staff observed with facial coverings. LPA toured vacant resident rooms. LPA toured the community kitchen and observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA observed a 30-day supply of PPE and cleaning supplies. LPA checked residents' medication and observed a 30-day supply.

No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 03/11/2022: Current
copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization
(LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan,
Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator . As a COVID-19 precautionary measure, a copy of this report will be provided via email. Report signed on-site by Facility Representative.
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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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