<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547200930
Report Date: 10/15/2021
Date Signed: 10/15/2021 04:18:13 PM

Document Has Been Signed on 10/15/2021 04:18 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:D.P. BUTLER HOMEFACILITY NUMBER:
547200930
ADMINISTRATOR:BUTLER, DIANAFACILITY TYPE:
735
ADDRESS:3500 W. VICTORTELEPHONE:
(559) 635-0224
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 4DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Diana Butler, LicenseeTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/15/2021, 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 Diana Butler, Licensee. Upon entry staff was observed not wearing facial covering. All four residents were present during the inspection.

LPA conducted tour with Licensee. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing and cough etiquette postings observed in facility. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Medications were kept in a locked safe in kitchen and 30-day PPE supplies observed. Cleaning supplies were stored and locked under kitchen sink. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 06/12/21.

LPA observed hand washing posting by all sinks. All bathrooms are observed with trash cans with lid. All resident’s room toured and observed to be adequately furnished and lit. LPA observed resident’s bedroom with no trash bin with a lid. LPA observed 2 shared resident’s bedrooms to be at least 6 feet apart.

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 residents’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following forms were requested: LIC 308, LIC 500, LIC 610D, and LIC 9020. Please submit the above forms/information to Fresno CCL by: 10/21/21. LPA received copy of Administrator Certificate during facility inspection. Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3