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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201111
Report Date: 01/08/2025
Date Signed: 01/08/2025 01:22:43 PM

Document Has Been Signed on 01/08/2025 01:22 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/
DIRECTOR:		LOPEZ, TAIMIFACILITY TYPE:
735
ADDRESS:1741 W. VINETELEPHONE:
(559) 713-0145
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 6CENSUS: 6DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Taimi LopezTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 1/08/2025, Licensing Program Analyst (LPA) M Medina conducted an unannounced Annual Required inspection. LPA arrived, introduced self, stated purpose of visit, and allowed entrance by Administrator, Tami Lopez.

Currently, there are six (6) residents in care. All residents were at day program at time of inspection, residents attend Day Program, Monday through Friday 8:00 AM - 2:30 PM. Facility tour conducted both inside and outside of facility. Facility observed to be clean, odor free, and a comfortable temperature. All residents have private bedrooms, resident rooms observed to have all required furnishing available. Bathrooms toured, LPA observed fixtures to be operational, water temperature measured at 108 degrees F. LPA observed the following, Wall behind toilet in hallway bathroom observed to have peeling paint, and wall observed to be moist. The tub/shower in hallway bathroom and master bathroom observed to be worn, may require repair and/or replacement. LPA observed the carpet in hallway from dining room to resident bedrooms observed to be rippled, which may be a potential tripping hazard. Kitchen toured, all knives observed to be locked and secured in kitchen drawer. All cleaning supplies observed to be locked under kitchen sink with additional supples secured in laundry room. Facility observed to have a 2-day supply of perishable food and a 7-day supply on non-perishable food available for residents. Medications observed to be locked and secured in kitchen cabinet. All medications observed to have original labels and observed to be administered as prescribed.

Outside of facility toured. Pool observed to be surrounded by a locked and secured gate and inaccessible to residents. LPA observed unused wrought iron fencing on the east side of house leaning against fence, which needs to be removed. All exits open free of obstruction.

Resident and staff files reviewed

Deficiency cited on the attached 809D. Exit interview conducted. A copy of this report provided to Administrator for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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 2
Document Has Been Signed on 01/08/2025 01:22 PM - It Cannot Be Edited


Created By: Melinda Medina On 01/08/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DAGO RESIDENTIAL FACILITY
FACILITY NUMBER: 547201111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which LPA observed the following, Wall behind toilet in hallway bathroom observed to have peeling paint, and wall observed to be moist. The tub/shower in hallway bathroom and master bathroom observed to be worn, may require repair and/or replacement. LPA observed the carpet in hallway from dining room to resident bedrooms observed to be rippled, which may be a potential tripping hazard, unused wrought iron fencing observed on the east side of facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator to remove unused wrought iron fencing on east side of facility. Administrator will have estimates done for repair/replacement of carpet, tub/shower area for both bathrooms, wall behind toilet in hallway bathroom.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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