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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206701
Report Date: 10/22/2024
Date Signed: 10/22/2024 12:55:51 PM


Document Has Been Signed on 10/22/2024 12:55 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: DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Standards Compliance Coordinator, Cheryl Cardoza, Acting Administrator, Thomas DesRosiers, Registered Nurse-QA, Rey David Barisoro, Supervising Registered Nurse Priscilla Medina, and Supervising Registered Nurse, Elisa PakinganTIME COMPLETED:
01:10 PM
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On 10/22/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct and annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Administrator, Scott Richards, is not available to meet during today's inspection. LPA met with Standards Compliance Coordinator, Cheryl Cardoza, Acting Administrator, Thomas DesRosiers, Registered Nurse-QA, Rey David Barisoro, Supervising Registered Nurse Priscilla Medina, and Supervising Registered Nurse, Elisa Pakingan.

LPA toured buildings 2A, 3B, and 4A during today's inspection. The facility appeared to be clean, odor free, and at a comfortable temperature. The common areas were furnished well with adequate seating and lighting available. Each building has a small kitchen/dining area for resident use. LPA toured bedrooms 210, 212, 333, 334, and 433. LPA observed bedrooms to have required furnishings and adequate lighting. Bathrooms were toured. LPA observed secure grab bars equipped in the shower and toilet areas. The facility bathroom is equipped with non-skid floor tiles. Hot water ranged between 115.8 degrees F and 121.4 degrees F. Main kitchen toured. Kitchen appeared clean and safe for food preparation. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Fire extinguishers were last serviced on 11/02/2023.

LPA reviewed facility records. Residents records were found to be complete and current. Personnel records were found to be complete and current. LPA reviewed the facility emergency disaster plan. Last fire drill was conducted on 09/06/2024. Smoke detector and carbon monoxide detector observed to be operational during today's visit. 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 11/05/2024: 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 Acting Administrator, Thomas DesRosiers, 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: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024
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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