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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204013
Report Date: 11/07/2022
Date Signed: 11/07/2022 04:00:46 PM

Document Has Been Signed on 11/07/2022 04:00 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:MILLER-ANGELO ARFFACILITY NUMBER:
107204013
ADMINISTRATOR:MILLER-ANGELO, DIANNAFACILITY TYPE:
735
ADDRESS:5321 WEST HOME AVENUETELEPHONE:
(559) 412-8797
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 6DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Dianna MillerTIME COMPLETED:
04:08 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Inspection - Infection Control. LPA met with and explained the purpose of the visit with Administrator (AD) Dianna Miller.

LPA toured the facility inside and out. Upon entry, LPA observed visitor log/symptom screening and sanitizer. Covid-19 symptom and precautionary signs are posted at entry and throughout the facility. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed soap, paper towels in bathrooms. LPA observed required food supply, paper products, available PPE and resident medications. Cleaning/disinfecting products were locked. LPA reviewed resident emergency contact information. Fire and Carbon Monoxide alarms were observed in working order. LPA observed fire extinguishers dated 5/15/22. AD purchased additional PPE to increase supply during the visit. Requirements for face coverings was reviewed with AD and staff who were present.

No deficiencies were cited during this inspection.

LPA Emailed Infection Control PIN-22-18-ASC and Infection Control Template to AD. AD has agreed to submit the Infection Control Plan to CCLD by 12/7/22


An exit interview was conducted. A copy of this report was left with Dianna Miller whose signature confirms receipt of these documents.

LPA requested the following updated forms by 11/21/22: LIC 308, LIC 400, LIC 402, LIC 500, LIC 610,
LIC 9020, a copy of current Liability Coverage and Administrator Certificate.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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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