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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100405566
Report Date: 02/16/2022
Date Signed: 02/16/2022 03:59:56 PM


Document Has Been Signed on 02/16/2022 03:59 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:PRINCE & PRINCESS HOME FOR THE ELDERLYFACILITY NUMBER:
100405566
ADMINISTRATOR:PRINCE, BETTYFACILITY TYPE:
740
ADDRESS:4686 E. CORTLANDTELEPHONE:
(559) 231-5728
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:6CENSUS: 4DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Administrator Betty PrinceTIME COMPLETED:
04:15 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 Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Administrator Betty Prince and discussed the purpose of the visit. LPA and Administrator began the tour at the front entrance/office of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/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 observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked doo. LPA observed the following personal protective equipment in a storage cabinet in garage; gowns, face shield, gloves, and masks. LPA observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

LPA observed pool to be behind a locked gate. Pool is green and needs to be serviced. Facility grounds needs to be cleaned and front bathroom is in disrepair. Facility does not have a mitigation plan and will submit by POC due date. Refer to 809d.

Exit interview was conducted and a copy of this report was provided via email.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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 2


Document Has Been Signed on 02/16/2022 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER: 100405566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having a bathroom in disrepair, a backyard that needs cleaning and a pool that needs to be cleaned, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
1
2
3
4
Licensee agrees to conducts repairs and clean facility by POC due date. LPA will conduct visit for POC.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2