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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206701
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:16:44 PM


Document Has Been Signed on 07/16/2024 04:16 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: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: 126DATE:
07/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:39 PM
MET WITH:Administrator, Scott Richards and Supervising Registered Nurse Priscilla MedinaTIME COMPLETED:
04:30 PM
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On 07/16/2024, Licensing Program Analysts (LPAs) Walton and Leffall arrived unannounced to conduct a case management inspection. LPAs introduced themselves, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Administrator, Scott Richards and Supervising Registered Nurse Priscilla Medina.

The purpose of today's visit is to follow up on a self-reported incident.

No deficiencies issued.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Scott Richards, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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