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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202403
Report Date: 02/17/2022
Date Signed: 02/17/2022 02:15:08 PM


Document Has Been Signed on 02/17/2022 02:15 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:GRAYSFUL LIVINGFACILITY NUMBER:
107202403
ADMINISTRATOR:FLAUTA, VICTOR S.FACILITY TYPE:
740
ADDRESS:1552 E. MUNCIE AVETELEPHONE:
(559) 297-0233
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Assistant Administrator, Patricia HernandezTIME COMPLETED:
12:30 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
On 02/17/2022, Licensing Program Analyst (LPA) Walton arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Administrator is not present in the facility at this time. Facility staff contacted Administrator. LPA met with Assistant Administrator, Patricia Hernandez who arrived a short time later.

COVID-19 guidelines are in place. Facility has one central entrance and exit. Facility has implemented a sign-in policy for visitors.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lids. Hand washing posters were observed by the bathroom sink. 4 bedrooms are single occupant and 1 bedroom is shared. Beds in the shared bedroom appeared to be at least 6 feet apart.

LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Facility staff was observed with mask on. Residents wear masks when away from the community. 4 of 6 Resident’s files have updated emergency contact information.

CONTINUED TO LIC809C

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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


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: GRAYSFUL LIVING
FACILITY NUMBER: 107202403
VISIT DATE: 02/17/2022
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
26
27
28
29
30
31
32
LPA is requesting the following documents be submitted to the Fresno CCL office by 03/03/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan LIC 610E, Personnel Report (LIC500), Register of Facility Clients/Residents for, Surety Bond*.

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report will be provided via email due to COVID-19 precautionary measures. Report signed on site by Facility Representative.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2