107202403-1-19-2023-24-AS-VGON-CN8NDJ-20230119092225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107202403
Report Date: 01/18/2023
Date Signed: 01/19/2023 09:22:44 AM

Document Has Been Signed on 01/19/2023 09:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	GRAYSFUL LIVING		FACILITY NUMBER:	107202403
ADMINISTRATOR:	FLAUTA, VICTOR S.		FACILITY TYPE:	740
ADDRESS:	1552 E. MUNCIE AVE		TELEPHONE:	(559) 297-0233
CITY:	FRESNO	STATE: CA	ZIP CODE:	93720
CAPACITY:	6	CENSUS: 6	DATE:	01/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Main Caregiver, Nancy Wade		TIME COMPLETED:	04:30 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 01/18/2023, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Main Caregiver, Nancy Wade. Administrator Assistant, Jill Stowell, was notified of Licensing visit but was unable to attend the inspection due to family needs. Visitor log-in/temperature check station was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff was observed with mask covering. The facility was observed to be at a comfortable temperature, free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. PPE were observed in a laundry room locked. A 2-day supply of perishable and 7-day supply of non-perishable food was observed to be properly stored and labelled. Fire extinguisher was observed with a service date of 05/02/2022. Resident's all 6 bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Sample of residents file was reviewed for emergency contact. No deficiencies were observed. DOP was provided the source to Title 22 and PINs update information.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GRAYSFUL LIVING	FACILITY NUMBER: 107202403
	VISIT DATE: 01/18/2023

NARRATIVE

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LPAs are requesting the following documents to be provided to the Fresno CCL office by 01/30/2023: Current copy
Of:

LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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