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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209068
Report Date: 02/28/2022
Date Signed: 03/01/2022 07:16:23 PM


Document Has Been Signed on 03/01/2022 07:16 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/01/2022 03:47 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

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On 02/28/2022, Licensing Program Analysts (LPAs) L. Salazar and S. Doucette arrived at the facility unannounced to conduct Health & Safety checks on resident's in care. LPAs were greeted by Residential Care Coordinator (RCC), stated the purpose of the visit and were allowed entry into the facility. COVID precautionary measures were taken at the time of entry. Memory Care was toured by LPA Doucette and Assisted Living was toured by LPA Salazar. Collectively, issues and/or deficiencies were observed in relation to the following, which will be addressed at a later visit.

87615 Prohibited Health Conditions


87616 Exceptions for Health Conditions
87612 Restricted Health Conditions
87613 General Requirements for Restricted Health Conditions
87628 Diabetes
87633 Hospice Care of Terminally Ill Residents
87705 Care of Persons with Dementia
87609 Allowable Health Conditions and the Use of Home Health Agencies
87466 Observation of the Resident
87611 General Requirements for Allowable Health Conditions
87608 Postural Supports
87465 Incidental Medical and Dental Care
87618 Oxygen Administration - Gas and Liquid
87405 Administrator - Qualifications and Duties
87204 Limitations - Capacity and Ambulatory Status
87303 Maintenance and Operation
Exit interview conducted with RCC and a copy of this report was provided.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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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