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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209164
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:16:04 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:DIGNITY MANOR SENIOR HOMEFACILITY NUMBER:
107209164
ADMINISTRATOR:GAYNOR, DONTEFACILITY TYPE:
740
ADDRESS:1828 SANTA ANA AVE.TELEPHONE:
(559) 917-0440
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Licensee, Camalah KopaczTIME COMPLETED:
10:56 AM
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On 09/21/2021, Licensing Program Analysts (LPA) A. Walton conducted an unannounced Case Management Visit. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensee, Camalah Kopacz.

The purpose of today's visit is to amend the Pre-licensing Inspection report dated 09/17/2021.

No deficiencies issued.

An exit interview was conducted. As a COVID-19 precautionary measure, a copy of this report will be provided to Licensee via email and an electronic read receipt confirms receiving this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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