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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209059
Report Date: 10/20/2021
Date Signed: 10/21/2021 09:13:06 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: 4DATE:
10/20/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Erica Dominguez, Caregiver and Jennifer Ferguson Administrator via telephoneTIME COMPLETED:
10:00 AM
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On 10/20/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPA was met by Caregiver Erica Dominguez. Jennifer Ferguson, Administrator was called by caregiver. Administrator states unable to meet with LPA and authorized caregiver to conduct visit and sign report with LPA. All four residents were present during the inspection.

LPA conducted tour with caregiver. Facility staffs was observed with mask on. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. LPA checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked under kitchen sink and in office.

Social distancing is maintained in the common and dining areas. All bathrooms are observed with trash cans with lid and securely fastened grab bars. Bathrooms have non-skid mat. LPA observed hand washing posting by all sinks. Social distancing postings observed in facility. LPA did not observe cough etiquette postings. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 1 shared resident’s bedroom to be at least 6 feet apart and 2 bedrooms that are single occupant.

The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed fire extinguisher served date: 10/20/21. All residents’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. Please submit the requested forms to Fresno CCL by: 10/26/21. The following updated forms were requested: LIC 308, LIC 500, LIC 610E, and LIC 9020. Administrator and caregiver was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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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