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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206566
Report Date: 08/26/2024
Date Signed: 08/26/2024 01:42:44 PM

Document Has Been Signed on 08/26/2024 01:42 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:J & M ELDERLY HOMECAREFACILITY NUMBER:
547206566
ADMINISTRATOR/
DIRECTOR:		PIRA, J. & RAFANAN, M.FACILITY TYPE:
740
ADDRESS:3510 W. ELOWIN AVENUETELEPHONE:
(559) 303-8043
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 6CENSUS: 4DATE:
08/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:37 AM
MET WITH:Melanie RafananTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 8/26/24, Licensing Program Analyst (LPA) M Medina arrived unannounced to Case Management Annual Continuation. LPA arrived, introduced self, and stated purpose of visit. Administrator, Melanie Rafanan contacted by telephone and arrived a short time later.

LPA Medina completed inspection tool and reviewed a sample of staff files.

LPA Medina conducted physical plant tour during initial inspection on 7/30/24 and documented on original report.

LPA recevied copies of the following documents during Annual Continuation visit: LIC 308 (Designation of Facility Responsibility), LIC 500 (Personnel Report), LIC 610E (Emergency and Disaster Plan), LIC 9020 (Register of Facility Clients/Residents).

Exit interview conducted.

No deficiencies cited.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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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