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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100403618
Report Date: 11/17/2021
Date Signed: 11/17/2021 03:23:40 PM

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:MAPLE AVENUE GUEST HOMEFACILITY NUMBER:
100403618
ADMINISTRATOR:ARCUINO, ELDADFACILITY TYPE:
740
ADDRESS:3341 NORTH MAPLE AVENUETELEPHONE:
(559) 227-9722
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:14CENSUS: 13DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator, Camalah Kopacz TIME COMPLETED:
03:22 PM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator, Camalah Kopacz , and discussed the purpose of the visit.

LPA Williams toured the facility.

LPA Williams observed a visitor/temperature log, masks, and hand sanitizer station. Facility has one entry and exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked door and medication behind a locked cabinet. LPA Williams observed the following personal protective equipment in storage; gown, goggles, gloves, and masks.
LPA Williams observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

No deficiencies were cited at this time.

Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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