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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206701
Report Date: 09/27/2023
Date Signed: 09/27/2023 01:28:17 PM


Document Has Been Signed on 09/27/2023 01:28 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: 124DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Standards Compliance Coordinator, Cheryl Cardoza and Administrator, Scott RichardsTIME COMPLETED:
01:42 PM
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On 09/27/2023, Licensing Program Analysts (LPAs) Walton and Padgett arrived at the facility unannounced to conduct an Annual Required Inspection. LPAs introduced themselves, stated the purpose of the visit, and requested to meet with the Administrator. LPAs met with Standards Compliance Coordinator, Cheryl Cardoza and Administrator, Scott Richards.

LPAs conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. LPAs toured the following rooms: 224, 217, 213, 328, 324, 356, 458, 442, 418, 420. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, and resident bathrooms were equipped with non-skid tiles. Hot water temperature measured between 113.5 and 119.8 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 11/2/2022. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 08/22/2023.

LPAs reviewed staff and client records. Medications reviewed and observed to have original labels and be administered as prescribed.

No deficiencies issued during today’s visit

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/11/2023: 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), Surety Bond

Exit interview conducted. A copy of this report was discussed and provided to Administrator, 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: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
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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