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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208944
Report Date: 06/09/2023
Date Signed: 06/09/2023 12:49:42 PM


Document Has Been Signed on 06/09/2023 12:49 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
SIERRA CASCADE AC/SC, 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: 4DATE:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee Camalah Kopacz TIME COMPLETED:
10:45 AM
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On 6/9/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a subsequent Annual visit. LPA introduced self, stated the purpose of the visit, and was greeted by caregiver Pauline Simpson Cox. LPA was granted entry into the facility. Licensee (L1) Camalah Kopacz was called and arrived shortly. LPA toured facility with L1. All four clients were present upon LPA arrival. LPA conducted interviews with staff and resident.MARs was reviewed. All residents’ file reviewed to have update emergency contacts and Admission agreement, and Pre-Appraisal. Sample of staff's files were also reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.

The tour started in the kitchen into the common areas, to the resident's bedrooms, and bathrooms. LPA
observed COVID-19 related signs. The facility was observed to be at a comfortable temperature of 77 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. Fire extinguisher was observed with a service date of: 06/02/23. Fire drill last completed: 04/14/23. Cleaning supplies and chemicals stored and locked in garage cabinet. LPA toured all resident’s bedrooms and observed 4 single occupant rooms. Residents’ room observed to be adequately furnished with bed, dresser, and adequate lighting. Bathrooms were properly equipped, and the hot water temperature was tested at 109.6 degrees F in bathroom 1 and 109.21 degrees F in bathroom 2. Medications are kept locked in hall closet. Outside of facility toured and observed to be free of debris. Carbon monoxide and smoke
detectors were tested and observed to be operational.

No deficiencies issued during this inspection Exit Interview conducted. The following documents are
requested and submitted to Fresno CCL by: 6/15/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, current liability insurance, control of property, transportation procedure, theft and loss policy/procedure, and current Administrator certificate. A copy of this report was provided to Licensee.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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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