107209164-9-17-2021-24-AS-AWAN-C6XQ3U-20210917114919

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209164
Report Date: 09/17/2021
Date Signed: 09/17/2021 11:50:28 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:	DIGNITY MANOR SENIOR HOME		FACILITY NUMBER:	107209164
ADMINISTRATOR:	GAYNOR, DONTE		FACILITY TYPE:	740
ADDRESS:	1828 SANTA ANA AVE.		TELEPHONE:	(559) 917-0440
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 4	DATE:	09/17/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Licensee, Camalah Kopacz		TIME COMPLETED:	11:55 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/17/2021, Licensing Program Analysts (LPAs) A. Walton and M. Yang conducted an announced Prelicensing and Component III inspection. LPAs introduced selves, stated the purpose of the visit, and was granted entry into the facility. LPAs met with Licensee, Camalah Kopacz. The facility is 5 bedroom and 3 bathroom home. Fire clearance was granted for 6 Non-Ambulatory for total of 6 capacity. There are 4 residents present during this inspection. Facility temperature is set to 75 degrees F. LPAs toured the facility with Licensee. Common areas were furnished and had adequate seating and lighting available. Bedrooms were observed to have required furnishings. Hot water measured at 113.7 degrees F in bathroom 1 and 111.7 degrees F in the bathroom in the shared bedroom. LPA observed an extra supply of bed linens and personal hygiene products. Kitchen was toured and observed to have dishes, plate, and utensils. LPAs observed a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. Knives were observed to be locked and secure in a lock box on the kitchen counter. Cleaning supplies and chemicals were observed to be in a locked cabinet in the garage. Medications were kept locked and inaccessible to residents in care. First aid kit was observed and contained all required items. A fire extinguisher was observed and has a service date of 05/29/2021. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching. Resident records were reviewed. LPAs observed resident Admission Agreements and Physician Reports. Staff records were reviewed. 5 out of 7 personnel records did not have a criminal record clearance. LPAs confirmed in LIS that staff are cleared and associated to the facility. Last fire drill conducted on 07/07/2021.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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 MANOR SENIOR HOME	FACILITY NUMBER: 107209164
	VISIT DATE: 09/17/2021

NARRATIVE

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Component III was conducted during today's pre-licensing visit.

LPAs requested the following items be repaired by the Licensee: leaking faucet and shower heads in bathroom near bedroom 1, install window screen to the window in the shared bedroom, and submit pest control receipts.

Exit interview conducted. A copy of this report will be provided to Licensee due to COVID-19 precautionary measures.

LPAs will notify CAB that the facility is ready to be licensed once the above information has been received.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3

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 MANOR SENIOR HOME	FACILITY NUMBER: 107209164
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	Amended.
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC809 (FAS) - (06/04)

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