<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208889
Report Date: 11/08/2023
Date Signed: 11/08/2023 03:34:55 PM


Document Has Been Signed on 11/08/2023 03:34 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:LAVERNE SENIOR CAREHOMEFACILITY NUMBER:
107208889
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:3194 LAVERNE AVETELEPHONE:
(559) 292-0074
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Elisa PuaTIME COMPLETED:
03:34 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/08/2023, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA Medina introduced self, purpose of visit and allowed entrance by caregiver. Administrator, Elisa Pua arrived a short time later to conduct facility inspection. Arlene Bautista, Administrator Certificate #6024205740, expires 1/4/2025.

Currently, five (5) residents in care. All residents were present during today's inspection and observed to be resting.

Facility tour began in resident bedrooms. Rooms observed to have all required accommodations. All areas of the facility have sufficient lighting. Residents bathrooms observed to be clean and in good repair. Bath/tub are have non-skid mats and grab bars. Hot water tested in both bathrooms with a water temperature of 120 degrees F. Dining room and living room have adequate seating and lighting for all residents in care. Tour of kitchen conducted. LPA observed adequate food supply for the residents in care. LPA observed leftovers stored in the refrigerator and/or freezer observed to be properly stored and labeled. Medications observed to be locked and secured in kitchen cabinet. All medications observed to have original labels and administered as ordered.

Smoke detectors tested and observed to be operational at time of visit. Carbon monoxide detectors present and visible in dining room and in hallway near resident bedrooms. Fire extinguisher has a purchase date of 5/19/23. Last fire drill conducted on 7/08/23 according to facility records. Cleaning supplies observed to be locked and secured under kitchen sink, in laundry room and in locked cabinet in the garage.

Outside areas toured. All exits open freely and observed to be free of obstruction. No hazards observed.

No deficiencies cited during visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1