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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201437
Report Date: 11/30/2021
Date Signed: 11/30/2021 12:29:34 PM

Document Has Been Signed on 11/30/2021 12:29 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 CARE HOME IIFACILITY NUMBER:
547201437
ADMINISTRATOR:ANTONIO DIAZFACILITY TYPE:
735
ADDRESS:2128 SOUTH ASHTON COURTTELEPHONE:
(559) 738-1008
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 6DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Vanessa Garduno, AdministratorTIME COMPLETED:
01:00 PM
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On 11/30/2021, 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 requested to meet with administrator. LPA met with caregiver Maria Shuman. Vanessa Garduno, Administrator was called and arrived shortly. LPA conducted tour with administrator. All six residents were present during the inspection.

Facility staff was observed with mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents 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 checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in laundry room.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 3 bedrooms shared resident’s bedroom to be at least 6 feet apart.LPA toured bathroom. LPA observed trash bin with lid in bathroom. LPA observed hand washing posting by all sinks.

The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed fire extinguisher served date: 12/28/20. Last fire drill 11/01/2021.

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 documents are requested and submitted to Fresno CCL by: 12/06/21. The following updated forms were requested: Lic 400, Lic 402, Lic 500, Lic 610D, Lic 808, Lic 9020. 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. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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