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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206929
Report Date: 02/25/2022
Date Signed: 02/25/2022 02:08:40 PM


Document Has Been Signed on 02/25/2022 02:08 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:PAINTBRUSH ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
107206929
ADMINISTRATOR:JENNIFER VASQUEZFACILITY TYPE:
740
ADDRESS:4356 W ASHLAN AVETELEPHONE:
(559) 275-2000
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:110CENSUS: 90DATE:
02/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Marilyn Couzens, LVNTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a Case Management visit. LPA met with Resident Care Director Marilyn Couzens, LVN (RCD) and explained the purpose of the visit.

The facility submitted a SOC341 and Special Incident Report (SIR) on 2/16/22. The SIR reported an incident that occurred in the parking lot of the facility 2/14/2022 between a former staff member S1 and current staff member S2 Resident R1 was present at the time of the incident. No harm or injury occurred as a result of the incident. The facility called 911 and a Police Report was filed. LPA obtained a copy of the Police Report.

LPA interviewed R1 and S2 during this visit.








No citations are issued during this visit.

A copy of this report was provided, and an exit interview conducted with RCD.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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