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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206701
Report Date: 08/25/2022
Date Signed: 08/25/2022 11:04:42 AM


Document Has Been Signed on 08/25/2022 11:04 AM - 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: 162DATE:
08/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Administrator, Scott Richards and Standards Compliance Coordinator, Cheryl Cardoza TIME COMPLETED:
11:12 AM
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On 08/25/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management Inspection. LPA introduced self, stated the purpose of the visit and met with Administrator, Scott Richards and Standards Compliance Coordinator, Cheryl Cardoza.

The purpose of today's visit is to follow up on an incident that was reported to the Fresno CCL office on 08/09/2022. It was reported that R1 was struck by a vehicle while riding R1's bike.

LPA obtained the following documents for R1: LIC602, Needs and Services Plan, Admission Agreement, and Emergency contact information.

No deficiencies issued during this visit.

An exit interview was 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: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
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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