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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201111
Report Date: 01/30/2023
Date Signed: 01/30/2023 10:14:56 AM

Document Has Been Signed on 01/30/2023 10:14 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:DAGO RESIDENTIAL FACILITYFACILITY NUMBER:
547201111
ADMINISTRATOR:LOPEZ, TAIMIFACILITY TYPE:
735
ADDRESS:1741 W. VINETELEPHONE:
(559) 713-0145
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 6CENSUS: 6DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Administrator, Taimi LopezTIME COMPLETED:
10:29 AM
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On 01/30/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection - infection control. LPA introduced self, stated the purpose of visit and was granted entry to the facility by Administrator, Taima Lopez. Facility has one central entrance and exit.

Facility tour conducted. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPA observed a 30 day supply of PPE and cleaning supplies.

Bedrooms checked. Beds observed to be at least six feet apart or three feet apart with head to toe orientation. Liquid soap and paper towels are available in the bathrooms. Hand-washing signs observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply. Resident and staff temperature checks are documented daily. Resident's records reviewed for updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 02/13/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

No deficiencies issued. Exit interview conducted A copy of this report was discussed and provided to Administrator, Taima Lopez, whose signature on this form confirms receipt of this document

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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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