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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201111
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:19:05 PM

Document Has Been Signed on 01/17/2024 12:19 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: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:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Taimi LopezTIME COMPLETED:
12:40 PM
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On 1/17/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required visit. LPA introduced self, stated purpose of visit, and allowed entrance by Administrator Taimi Lopez.

Currently, there are six (6) clients in care. Facility tour conducted. Facility observed to be clean and odor free. Adequate seating and lighting observed in all common areas. Client bedrooms have all required accommodations. Client bathroom toured, LPA measured water temperature 112 degrees F. Kitchen toured, LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food. Medications observed to be kept in a locked closet in hallway. Client medications were reviewed. All medication have their original labels and appear to be administered as ordered. All cleaning supplies are locked and secured in garage. Smoke detectors and carbon monoxide observed to be operational during today's inspection. Fire extinguisher present with a service date of 12/04/2023. Last Fire Drill conducted 1/01/2024 according to facility records..

Outside of facility toured. Pool is surrounded by gate that is locked, secured, and inaccessible to residents. All exits open free of obstruction, no hazards observed.

LPA is requesting the following document to be submitted to Fresno Regional office no later than 1/31/2024: Personnel Report (LIC 500), Register of facility Clients/Residents (LIC 9020).

No deficiencies cited during today's visit. Exit interview conducted and a copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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