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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206701
Report Date: 10/27/2021
Date Signed: 10/27/2021 11:58:14 AM

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:VETERANS HOME OF CALIFORNIA-FRESNOFACILITY NUMBER:
107206701
ADMINISTRATOR:SCOTT H. RICHARDSFACILITY TYPE:
740
ADDRESS:2811 W. CALIFORNIA AVENUETELEPHONE:
(559) 493-4400
CITY:FRESNOSTATE: CAZIP CODE:
93706
CAPACITY:186CENSUS: 152DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Administrator, Scott Richard, Infection Preventionist Ronnel Cruz, and Supervising Registered Nurse, Jasleen DhillonTIME COMPLETED:
12:00 PM
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On 10/27/2021, Licensing Program Analyst (LPA) A. Walton 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 Administrator (ADM), Scott Richards, Infection Preventionist (IP), Ronnel Cruz, and Supervising Registered Nurse (SRN), Jasleen Dhillon. The facility has one central entrance and exit. Upon entry, LPA was screened for COVID-19 symptoms. LPA observed a visitor log-in/temperature check at facility entrance.

LPA conducted a facility tour with ADM, IP, and SRN. Buildings 2 and 3 were toured. Facility documents resident temperature checks daily. Residents at the above facility have private apartments. Common bathrooms were observed to be stocked with paper towels and liquid soap and hand washing postings. LPA observed signs promoting social distancing, and cough/sneeze etiquette throughout the facility. Hand-sanitizer was readily available throughout the facility. The facility is cleaned and sanitized every 30 to 45 minutes including high traffic areas. LPA checked a sample of resident medications and observed a 30 day supply. Building 2 rooms 201-205 are utilized as an isolation unit. LPA observed trash cans with lid and a isolation cart stocked with PPE. Facility has at least a 30 day supply of PPE and cleaning supplies.

Tour continued to the dining room. Tables have been modified to allow for social distancing with two residents per table. Facility offers staggered meal times. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA reviewed a sample of resident records and observed residents to have updated emergency contact information. LPA reviewed a sample of personnel records for good health.

CONTINUED TO 809C
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VETERANS HOME OF CALIFORNIA-FRESNO
FACILITY NUMBER: 107206701
VISIT DATE: 10/27/2021
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LPA is requesting the following documents be submitted to the Fresno CCL office by 11/10/2021:
  • 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 (LIC9020A)

No deficiencies issued during this inspection.

Exit interview was conducted with ADM and SRN. As a COVID-19 precautionary measure, a copy of this report will be provided to ADM via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.

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

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
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