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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200150
Report Date: 04/04/2022
Date Signed: 04/04/2022 02:16:33 PM

Document Has Been Signed on 04/04/2022 02:16 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:DIAZ FAMILY CARE HOMEFACILITY NUMBER:
547200150
ADMINISTRATOR:DIAZ, DIANNA & ANTONIOFACILITY TYPE:
735
ADDRESS:1603 S. PEPPERTREE CT.TELEPHONE:
(559) 635-4360
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 4DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Vanessa GardunoTIME COMPLETED:
01:45 PM
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On 04/04/22, 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 met with Administrator Vanessa Garduno. LPA conducted a facility tour with Administrator. There are no client present during tour.

Upon entry facility staff was observed with facial mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients 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. LPA observed social distancing and cough etiquette postings in facility.

Food supply was checked and appeared to be an adequate supply. Cleaning supplies were locked and secured in laundry room. LPA observed 30-day PPE supplies. LPA checked clients’ locked medications. LPA observed fire extinguisher served date: 12/21/21. Last fire drill: 03/03/22.

All clients’ bedroom toured and observed to be adequately furnished and lit. LPA observed one shared client’s bed to be at least 6 feet apart and two single occupants. All bathrooms observed trash bin with lid. LPA observed hand washing posting by sink.

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 clients’ 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: 4/10/22. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610D, Lic 808, Lic 9020, and control of property. LPA received copy of facility sketch and update Administrator certificate.

Licensee was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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