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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203506
Report Date: 03/16/2022
Date Signed: 03/16/2022 10:36:38 AM

Document Has Been Signed on 03/16/2022 10:36 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SVS CLOVIS ADULT DAY PROGRAMFACILITY NUMBER:
107203506
ADMINISTRATOR:BANUELOS, CHERIFACILITY TYPE:
775
ADDRESS:155 PARK CREEK DRIVE, #101TELEPHONE:
(559) 323-0537
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 90CENSUS: 24DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alexandra Williams, AdministratorTIME COMPLETED:
10:45 AM
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On 3/16/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA met Administrator Alexandra Williams. 20 clients were present during the inspection.

LPA completed a tour of the facility with administrator. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. LPA observed 30-day PPE supply. Client restrooms were tour, observed to be clean, and operational. LPA observed hand washing posting by all sinks. Social distancing is maintained in the common areas. LPA observed social distancing and cough etiquette postings in facility.

The Day Program has five classrooms separated into cohort for activities. Facility is maintained at a comfortable temperature and no passageway obstructions or fire hazards were observed inside or outside. Client locked lockers were observed in the drama and movie room. LPA observed locked medications in Administrator office.

A sample of client files were also reviewed to have updated emergency contact information. Staff files have current 1st Aid and infection control training.

No deficiency observed.

Exit Interview conducted. The following documents are requested and to be submitted to Fresno CCL by: 3/22/22. The following updated forms were requested: Lic 308, Lic 309 (if applicable), Lic 500, Lic 610D, Lic 808 and Lic 9020. Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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