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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208775
Report Date: 09/21/2021
Date Signed: 09/21/2021 01:12:09 PM

Document Has Been Signed on 09/21/2021 01:12 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:MI CASITA CARE HOME IIIFACILITY NUMBER:
107208775
ADMINISTRATOR:JAIME, JUDITFACILITY TYPE:
735
ADDRESS:233 W NORWICH AVETELEPHONE:
(559) 349-2951
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 4CENSUS: 3DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Administrator, Judit JamieTIME COMPLETED:
12:00 PM
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On 09/21/2021, Licensing Program Analyst, M. Garza arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA contacted Administrator who arrived a short time later. LPA was greeted by Administrator, Judit Jamie and was allowed entry into the facility. LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. Resident observed in room.

Mitigation plan was reviewed and approved on 5/27/21. COVID-19 procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Staff were all observed wearing face coverings. Facility has designated visitation areas. Covered trash bins were observed. LPA observed a 30-day supply of resident medications. A supply of PPE was available but Administrator to provide additional PPE for staff. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying were observed.

Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices are found to be in compliance. No deficiencies cited on todays inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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