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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202867
Report Date: 04/20/2022
Date Signed: 04/20/2022 07:07:44 PM


Document Has Been Signed on 04/20/2022 07:07 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:MARIAN HOMES 4FACILITY NUMBER:
107202867
ADMINISTRATOR:JANARDHAN NAGARAJFACILITY TYPE:
740
ADDRESS:2542 FILBERT AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:50 PM
MET WITH:Administrator Ravi Stephen TIME COMPLETED:
07:15 PM
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On 04/20/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Feliciano (Felix) Galvez and Ricky Padual, caregiver. LPA tour facility with caregiver. Administrator Ravi Stephen and Sundari Susan Kendakur was called and arrived shortly during tour. All six residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility.

LPA checked residents’ locked medications. LPA observed small amount of PPE supplies in facility. 30 days PPE supplies storage in a central location. Food supply was checked and appeared to be an adequate supply.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed one shared resident’s bed to be at least 6 feet apart and four single occupants. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all bathroom sinks. The exterior tour was conducted. Side gate free of obstruction. Five of six resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 04/26/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 400, Lic 402, Lic 808, updated Administrator certificate, control of property, and current liability insurance. A copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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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