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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203448
Report Date: 08/09/2022
Date Signed: 08/09/2022 09:24:54 AM


Document Has Been Signed on 08/09/2022 09:24 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:JORDETH SENIOR CARE HOMEFACILITY NUMBER:
547203448
ADMINISTRATOR:CIANO CODANGOSFACILITY TYPE:
740
ADDRESS:2226 W PEREZ CTTELEPHONE:
(559) 739-1297
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:5CENSUS: 4DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee Davilyn MancillaTIME COMPLETED:
09:15 AM
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Licensing Program Analyst LPA Shawna Doucette and Vadim Gorban conducted an Annual Infection Inspection on this date. LPA was met by Staff Rosalinda Necesito and discussed the purpose of the visit. Licensee Davilyn Mancilla responded to the facility to assist with the inspection. LPA and Licensee Davilyn Mancilla began the tour at the front entrance/office of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Covid-19 related signs were observed in the common areas.

Cleaning supplies were observed locked in cabinet in the garage. LPA observed the following personal protective equipment in garage; gowns, gloves, face shields, hand sanitizer and masks. LPA observed all facility staff to be wearing masks upon arrival.

Resident’s files have updated emergency contact information. LPA's reviewed staff training for Covid.


Exit interview was conducted and a copy of this report was provided
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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