<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100403618
Report Date: 11/07/2022
Date Signed: 11/07/2022 02:17:36 PM


Document Has Been Signed on 11/07/2022 02:17 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: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:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Camalah KopaczTIME COMPLETED:
02:16 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 Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Inspection - Infection Control. Upon arrival, a staff member contacted Administrator (AD) Camalah Kopacz who arrived at the facility.

LPA toured the facility inside and out. Upon entry, LPA observed visitor log/symptom screening and sanitizer. Covid-19 symptom and precautionary signs are posted at entry and throughout the facility. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed soap, paper towels and hand washing postings in bathrooms. LPA observed required food supply, paper products, available PPE and resident medications. Cleaning/disinfecting products were locked. LPA reviewed resident emergency contact information. Fire and Carbon Monoxide alarms were observed in working order. LPA observed fire extinguishers dated 5/29/22.

AD has agreed to revise and re-implement the resident and staff daily symptom screening.

No deficiencies were cited during this inspection.




An exit interview was conducted. A copy of this report was left with Camalah Kopacz whose signature confirms receipt of these documents.

LPA requested the following updated forms by 11/21/22: LIC 308, LIC 400, LIC 402, LIC 500, LIC 610E,
LIC 9020, a copy of current Liability Coverage and Administrator Certificate.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1