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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209059
Report Date: 10/30/2020
Date Signed: 10/30/2020 11:40:39 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:FAMILY STYLE SENIOR ASSISTED LIVINGFACILITY NUMBER:
107209059
ADMINISTRATOR:FERGUSON, JENNIFERFACILITY TYPE:
740
ADDRESS:2202 STANFORD AVETELEPHONE:
(559) 246-0521
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 0DATE:
10/30/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Licensee, Jenny FergusonTIME COMPLETED:
04:43 PM
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On 10/30/2020 Licensing Program Analysts (LPA's) M. Garza and M. Medina met with Licensee, Jenny Ferguson to complete a Pre-Licensing visit via tele-video conference due to COVID precautionary measures.

LPA's toured facility. Common rooms have adequate furnishings and lighting. All of the resident bedrooms have required furnishings and adequate lighting. LPA's observed a supply of extra bed linens and personal hygiene and grooming products. Kitchen observed to have dishes, plates, utensils. Cleaning supplies will be stored in a locking cabinets in office. Medications will be kept in a locked medication cabinet in kitchen area. First aid kit contains all the required items. A fire extinguisher is present and has a current service date. Auditory alarms present on all doors and windows.

Outside of the facility toured. All fire exits open free of obstruction. Perimeter of pool is surrounded by locked and secured gate. LPA's observed one of three bedrooms (identified as resident's bedroom) has direct access to body of water that could be a potential health and safety risk to residents.

All required postings are posted.Component III will be conducted during follow up visit.

LPA to conduct follow up visit upon completion of correction.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
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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