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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100407586
Report Date: 07/15/2021
Date Signed: 07/15/2021 04:08:36 PM

Document Has Been Signed on 07/15/2021 04:08 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:KAVILAND PLACEFACILITY NUMBER:
100407586
ADMINISTRATOR:TATUM, YVONNEFACILITY TYPE:
735
ADDRESS:4657 E. KAVILANDTELEPHONE:
(559) 266-5333
CITY:FRESNOSTATE: CAZIP CODE:
93725
CAPACITY: 6CENSUS: 3DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Yvonne TatumTIME COMPLETED:
04:30 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Staff Denise Darrough and Administrator Yvonne Tatum and discussed the purpose of the visit. LPA began the tour at the front entrance 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 door. LPA observed the following personal
protective equipment, which includes masks, gloves, hand sanitizer, gowns, face shields
and N95 masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks. Resident’s files have updated
emergency contact information.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2021
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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