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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202421
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:33:33 PM

Document Has Been Signed on 10/22/2021 03:33 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:BRYANT-LITTLE HOME 2FACILITY NUMBER:
547202421
ADMINISTRATOR:BRYANT, JANICEFACILITY TYPE:
735
ADDRESS:2733 WEST COUNTRY LANETELEPHONE:
(559) 802-3589
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 4CENSUS: 4DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Elissa Duhaylonsod, Assistant AdministratorTIME COMPLETED:
01:45 PM
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On 10/22/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was met by caregiver Veronica Coronado and house manager Damon Bly. Upon entry staff was observed not wearing facial covering. LPA conduct tour with house manager. Elissa Duhaylonsod, administrator arrived in a short time later and conduct tour with LPA. All four residents were present during the tour.

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. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. LPA observed cough etiquette signs and social distancing. Food supply was checked and there appeared to be an adequate supply. LPA checked residents’ locked medications. LPA observed fire extinguishers with a service date of: 06/32/20. LPA did not observe a 30-day PPE supplies. All bathrooms are observed with trash cans with lid. LPA observed hand washing posting by bathroom sinks. All resident’s room that are single occupant toured and observed to be adequately furnished and lit.

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 have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit interview was conducted. Please submit the following forms/information to Fresno CCL by: 10/28/21. Requested forms/ information: LIC 308, LIC 309, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9020, and current lease agreement. LPA received copy of Administrator Certificate during facility inspection. Due to COVID-19 precautionary measures, a copy of this report and appeal rights will be provided via email. Report signed on-site

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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Document Has Been Signed on 10/22/2021 03:33 PM - It Cannot Be Edited


Created By: Mai Yang On 10/22/2021 at 01:01 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: BRYANT-LITTLE HOME 2
FACILITY NUMBER: 547202421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)
87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Fire Extinguisher has a service date of 06/23/2020, which poses an immediate health and safety risk to the residents.
POC Due Date: 10/23/2021
Plan of Correction
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Administrator states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 10/23/21.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021


LIC809 (FAS) - (06/04)
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