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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206929
Report Date: 11/21/2022
Date Signed: 11/21/2022 01:10:43 PM


Document Has Been Signed on 11/21/2022 01:10 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: 80DATE:
11/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jennifer VasquezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management visit. LPA met with and explained the purpose of the visit with with Administrator (AD) Jennifer Vasquez.

The purpose of the Case Management visit is to follow up on the following reports submitted by the facility:
1. Special Incident Report (SIR) submitted 11/8/22 regarding Resident R1 resulting in injury of unknown origin after a hospital stay. During the visit, LPA observed R1, conducted interviews and a record review of R1's file.

2. Facility submitted a SOC 341 and SIR for Resident R2 on 11/18/22 which resulted in a fall. Resident was sent to the hospital for evaluation and returned with no now orders and no injury noted. During the visit, LPA met with and interviewed R2, conducted interviews and a record review of R2's resident and hospice file.



There were no citations issued during this Case Management visit.



An exit interview was conducted, and a copy of this report was left with Jennifer Vasquez, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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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