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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209164
Report Date: 09/13/2022
Date Signed: 09/13/2022 05:59:21 PM


Document Has Been Signed on 09/13/2022 05:59 PM - It Cannot Be Edited

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: 6DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Licensee Camalah KopaczTIME COMPLETED:
06:00 PM
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On 9/13/22, 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 administrator. LPA met with Martin Myles, Caregiver. Licensee Camalah Kopacz was called and arrived shortly and conduct tour with LPA. All six residents were present during the inspection.

Upon entry facility staffs was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed. LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 06/2/22.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 1 shared residents’ bed to be at least 6 feet apart and 4 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. LPA observed 30-day PPE supplies. Cleaning supplies were locked and stored in the garage.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 9/19/22. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 808, Lic 9282, and current liability insurance. Administrator 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) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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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