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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206701
Report Date: 10/05/2022
Date Signed: 10/05/2022 10:10:02 AM


Document Has Been Signed on 10/05/2022 10:10 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: 158DATE:
10/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Administrator, Scott RichardsTIME COMPLETED:
10:24 AM
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On 10/05/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Scott Richards. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point

LPA conducted a facility tour. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have a trash cans with lid. Hand washing posters were observed by the bathrooms. Bedrooms are single occupant.

LPA checked residents’ locked medications. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked and there appeared to be an adequate supply. Facility staff was observed with mask on. Residents wear masks when away from the facility. Resident’s files have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/19/2022: 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

No deficiencies issued during this inspection. 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: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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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