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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209059
Report Date: 11/18/2020
Date Signed: 11/19/2020 10:52:12 AM

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:
11/18/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Jenny FergusonTIME COMPLETED:
04:43 PM
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On 11/18/2020 Licensing Program Analyst (LPA) M. Garza met with Licensee, Jenny Ferguson to complete a follow up Pre-Licensing visit. Visit was completed via tele-video conference due to COVID-19 precautionary measures.

During LPA's last visit on 10/30/20, it was noted that the perimeter of pool was surrounded by locked and secured gate. However, LPA observed one of three bedrooms (identified as resident's bedroom) had direct access to a body of water that could be a potential health and safety risk to residents. Licensee has since had the fence line moved so that the bedroom window no longer has direct access to the body of water.

All required postings are posted. Smoke and carbon monoxide detectors functioning at time of visit. Component III was conducted with Licensee. Facility is in compliance and ready to be licensed.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020
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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