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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 01:53:38 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Licensee Camalah KopaczTIME COMPLETED:
12:06 PM
NARRATIVE
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Licensing Program Analyst (LPA) Darius Williams conducted a Case Management facility visit. LPA Williams met with Licensee Camalah Kopacz and discussed the purpose of the visit.

At approximately 10:45 a.m., LPA Williams observed locks on 2 out of 2 perimeter fence gates; on the east and west side of the facility. The lock can not be accessed from inside the fence perimeter which prevents exit from the backyard to the street.

LPA Williams observed the facility sketch designating the West gate as Emergency Exit #2.

Fire Clearance Inspection document reflects on 5/19/2021, Clovis Fire Department did not authorize a locked perimeter gate.

Staff 1 reported the lock is on the gate to assist with residents wandering behavior.

Based on observation, interview, and record review, a deficiency was cited on attached LIC 809-D according to Title 22, Division 6, Chapter 8, Article 12, Section 87705(l)(2). Additionally, a civil penalty is being assessed according to Section 1569.49(c)(2)(A) of the Health and Safety Code.

Licensee immediately had the lock removed from the gate.

An exit interview, a copy of the report, and appeals rights were 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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DIGNITY GARDENS HOME
FACILITY NUMBER: 107208944
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited

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87705 Care of persons with Dementia, (l) The following initial and continuing requirements shall be met for the licensee to lock...perimeter fence gates:, (2) The licensee shall ensure that the fire clearance includes approval of...locked perimeter fence gates.

This requirement was not met evident by:
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Based on LPA's observation, interview, and record review the Licensee did not receive a fire clearance to lock perimeter fence gate identified as Exit #2 on the facility sketch, which poses an immediate health and safety risk to 6 out of 6 persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021
LIC809 (FAS) - (06/04)
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