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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208837
Report Date: 09/19/2022
Date Signed: 09/19/2022 09:33:32 AM


Document Has Been Signed on 09/19/2022 09:33 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:CATUIRA HOME IIFACILITY NUMBER:
107208837
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:2478 HANSON AVENUETELEPHONE:
(559) 515-6071
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Camalah Kopacz Administrator, Oscar Aninon caregiverTIME COMPLETED:
09:45 AM
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On 9/19/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with caregiver Oscar Aninon. LPA conducted tour with caregiver. Administrator Camalah Kopacz was called and arrived later during inspection. There are three residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed.

LPA checked residents’ locked medications. LPA observed 30 days PPE supplies. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 06/02/22.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed three shared residents’ bed to be at least 6 feet apart. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks.

The exterior tour was conducted. Side gate was self-closing and free of debris. Four of six resident records reviewed to have updated emergency contact information. Staff records were reviewed for good health and infection control training.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 9/26/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 500, Lic 610E, Lic 9282, and control of property. LPA received a copy of current liability insurance and Administrator certificate. A copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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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