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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209230
Report Date: 02/08/2023
Date Signed: 02/08/2023 10:28:18 AM


Document Has Been Signed on 02/08/2023 10:28 AM - 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:STANFORD COTTAGE ASSISTED LIVINGFACILITY NUMBER:
107209230
ADMINISTRATOR:VASQUEZ, MARTHAFACILITY TYPE:
740
ADDRESS:2202 STANFORD AVETELEPHONE:
(858) 342-4998
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
02/08/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Licensee Benjamin Carter, Licensee Chad Hall, and Administrator Martha Vasquez/ZapataTIME COMPLETED:
10:40 AM
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On 02/8/23, Licensing Program Analysts (LPA) M. Yang conducted an announced Pre-licensing / Component III Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry into the facility. LPA met with Licensee 1 (L1) Benjamin Carter, Licensee 2 (L2) Chad Hall, and Administrator (A1) Martha Vasquez/ Zapata.

LPA toured the facility with L1, L2, and A1. The facility is a 3 bedroom and 2-bathroom home and fire clearance were granted for 6 Non-Ambulatory for a total capacity of 6.

There are six resident presents during this inspection. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available. Cleaning supplies and chemicals observed to be stored and locked in facility office. Kitchen was toured and observed to have dishes, plates, and utensils. Fire extinguisher was observed and had a service date of 12/19/23. Knives and medications were kept locked and secure in the hall closet inaccessible to residents in care. First aid kit was observed and contained all required items.

All Bedrooms were observed to have the required furnishing and are ready for occupancy and beds to be 6 feet at least apart. Hot water measured at 107 degrees F in bathroom 1 and ranged 107.2 degrees F in the bathroom 2. LPA observed an extra supply of bed linens and personal hygiene products. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Outside of facility toured. Side gate was self-closing and free of obstructions. Resident records were reviewed. LPA observed resident Admission Agreements, Physician Reports, and Pre-Appraisal. Staff records were reviewed. Personnel records have a criminal record clearance.

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

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued. A copy of this report was provided to Licensee.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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