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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200922
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:27:14 PM

Document Has Been Signed on 10/21/2021 12:27 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:LOOP #3FACILITY NUMBER:
107200922
ADMINISTRATOR:LOOP, STEVEFACILITY TYPE:
735
ADDRESS:7931 NORTH BAIRD AVENUETELEPHONE:
(559) 299-9413
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 4CENSUS: 4DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Caregiver, Joseph RafananTIME COMPLETED:
12:30 PM
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On 10/21/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced at the above facility to conduct an Annual Inspection. Facility has one central entry and exit point. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. Facility staff contacted Licensee, LPA received verbal permission from Licensee to meet with Caregiver. LPA met with Caregiver, Joseph Rafanan. Upon entry, LPA observed a visitor log-in/temperature check. Facility staff observed to be wearing facial coverings.

There are three residents present during this inspection.

Facility tour conducted with Caregiver. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. LPA checked residents' medication and observed a 30 day supply. LPA toured the facility kitchen. LPA observed a 7-day supply of perishable foods and a 2-day supply of perishable foods. LPA observed a 30 day supply of PPE and cleaning supplies.

Facility has two private rooms and one shared room. Beds in the shared room were observed to be at least 6 feet apart. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs observed in resident bathrooms. Resident temperature checks are documented daily. Resident records have updated emergency contact information. Facility staff records reviewed for good health and infection control training.

Continued to LIC809C
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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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: LOOP #3
FACILITY NUMBER: 107200922
VISIT DATE: 10/21/2021
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No deficiencies issued during this inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 11/04/2021: 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 (LIC610-D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

Exit interview conducted with Caregiver As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Report was signed on-site by Facility Representative.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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