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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208944
Report Date: 07/14/2021
Date Signed: 07/14/2021 12:32:40 PM

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:DIGNITY GARDENS HOMEFACILITY NUMBER:
107208944
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:1637 GETTYSBURG AVETELEPHONE:
(559) 449-3711
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Staff, Lyn GeridoioTIME COMPLETED:
12:04 PM
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Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Visit. LPA Williams met with Staff Lyn Geridoio, and discussed the purpose of the visit.

LPA Williams toured the facility.

LPA Williams observed a visitor log/temperature check and disinfection station at the front entrance. Facility has one entry and exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked door. LPA Williams observed the following personal protective equipment in the closet; gown, face shield, gloves, and masks.

LPA Williams observed staff training records regarding Covid-19 mitigation and infection control. LPA Williams observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

No deficiency cited at this time.

Administrator Camalah Kopacz, provided verbal approval for Staff to sign report.

An exit interview was conducted a copy of this report was provided.

SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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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