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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206566
Report Date: 06/08/2021
Date Signed: 06/09/2021 06:52:04 AM

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:J & M ELDERLY HOMECAREFACILITY NUMBER:
547206566
ADMINISTRATOR:PIRA, J. & RAFANAN, M.FACILITY TYPE:
740
ADDRESS:3510 W. ELOWIN AVENUETELEPHONE:
(559) 303-8043
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:6CENSUS: 4DATE:
06/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Licensee Jose PiraTIME COMPLETED:
10:00 AM
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Licensing Program Analysts (LPA) Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Licensee Jose Pira and discussed the purpose of the visit.

LPA began the tour with the Licensee Jose Pira at the front entrance 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. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed locked in laundry room. LPA observed the following personal protective equipment in a storage cabinet; hand sanitizer, gloves, and masks. Licensee stated all other PPE is stored in an office off site. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

Licensee needs to submit a mitigation plan to LPA. Plan is not complete. LPA provided PINS for Licensee to refer too.

Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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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