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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209172
Report Date: 01/27/2022
Date Signed: 01/27/2022 04:15:12 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:VALLEY SPRING MEMORY CAREFACILITY NUMBER:
247209172
ADMINISTRATOR:HEADY, ARTHUR W.FACILITY TYPE:
740
ADDRESS:555 MILLER LANETELEPHONE:
(209) 270-2575
CITY:LOS BANOSSTATE: CAZIP CODE:
93635
CAPACITY:50CENSUS: 0DATE:
01/27/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bill Heady - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst(LPA) D. Ayers arrived at the facility and met with Administrator Bill Heady and Licensee Nick Guzzi for an announced Pre-licensing Inspection. The facility fire clearance was granted fifty non-ambulatory, with approved hospice waiver for six.

LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. LPA observed smoke detectors and carbon monoxide detectors to be functional. The facility had a designated, locked room for medication storage with three locked medication carts. LPA observed extra linens and towels. Facility had adequate amount of dishes and utensils.

The facility was adequately furnished, clean, and well-lit. LPA toured resident bedrooms and bathrooms and observed bedrooms to have required minimum furnishings. Bathrooms were clean and fixtures functioned properly. Non-skid mats and secure grab bars were observed. Outdoor area was free from hazards and had a covered patio section for seating. There were no pools or bodies of water on the property.

Administrator completed Component III Orientation. Pre-Licensing is complete and this facility has no deficiencies. A copy of this report was provided to the licensee via email.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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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