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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208900
Report Date: 02/19/2024
Date Signed: 02/19/2024 03:11:04 PM


Document Has Been Signed on 02/19/2024 03:11 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: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: 4DATE:
02/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Carlo SantosTIME COMPLETED:
03:16 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 2/19/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA arrived introduced self, stated purpose of visit, and allowed entrance by caregiver. Administrator not available to conduct today's inspection. Carlo Santos, Co-Administrator contacted by telephone and arrived a short time later to inspection visit.

Facility tour conducted. All residents were present during today's inspection. Facility observed to be clean, odor free, a comfortable temperature, and well lit. Facility has 6 private bedrooms and each bedroom has a 1/2 bathroom with grab bars available. Facility has one walk in shower room for all residents, shower room observed to have shower chair, grab bar, and non-skid flooring. Water temperature measured at 111 degrees F. Living room and dining room observed to have seating for all residents. Kitchen toured, facility observed to have a 2-day supply of perishable and a 7-day supply of non-perishable food available. All knives observed to be locked and secured and inaccessible to residents. Medication observed to be locked and secured in hallway closet. All medications observed to have original labels and be administered as prescribed.

Facility is equipped with fire sprinkler system. Fire extinguisher present with a service date of 7/02/2023. Last fire drill conducted 1/10/2024 according to facility records.

Outside of facility toured. All exits open free of obstruction.

Resident and staff file reviewed. No deficiencies

Exit interview conducted. A copy of this report provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2024
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