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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208900
Report Date: 04/04/2022
Date Signed: 04/06/2022 07:55:05 AM


Document Has Been Signed on 04/06/2022 07:55 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:CALIMYRNA ASSISTED LIVINGFACILITY NUMBER:
107208900
ADMINISTRATOR:PETERS, TYSONFACILITY TYPE:
740
ADDRESS:1545 W CALIMYRNA AVETELEPHONE:
(559) 412-2335
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 6DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Carlo Santos - AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a required annual inspection. LPA met with administrator Carlo Santos and announced the purpose of the visit. Administrator certificate is current with expiration date 10/30/2023.

LPA toured the facility inside and outside. The facility was adequately furnished and lit throughout. All passageways and exits were clear and free from obstruction. The facility had multiple fire extinguishers. All smoke and carbon monoxide detectors were observed to be functional. LPA observed a two-day supply of perishable food stuffs and a seven-day supply of nonperishable food stuffs which were stored properly in the facility. Medications were secured in a locked closet and appeared to be administered properly. LPA toured resident bedrooms and bathrooms. Resident bedrooms were adequately furnished, and bathrooms have required secure grab bars and nonskid mats. Facility emergency/disaster plan was reviewed. LPA's reviewed infection control guidelines and best practices with Administrator. Administrator agreed to provide LPA with LIC 610E, LIC 500, LIC 9020, and proof of liability insurance.

No deficiencies cited during the inspection. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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