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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206651
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:26:37 PM

Document Has Been Signed on 10/22/2021 03:26 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:EWING PALM HOME, LLCFACILITY NUMBER:
547206651
ADMINISTRATOR:EWING, ELIZABETH G.FACILITY TYPE:
735
ADDRESS:4836 W. JAMES CTTELEPHONE:
(559) 429-4856
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 4DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Elizabeth Ewing, AdministratorTIME COMPLETED:
11:00 AM
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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 met with Administrator, Elizabeth Ewing. Upon entry staff was observed not wearing facial covering.

LPA conducted tour with Administrator. All four residents were present during the tour. LPA did not observe visitor log-in/temperature check upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. LPA observed fire extinguisher served date: 04/05/21. Social distancing is maintained in the common and dining areas. Hand sanitizer was readily available to residents and visitors. LPA checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. LPA observed cleaning supplies locked and stored inside cabinet in garage. LPA observed trash bins with no lid in bathrooms. LPA did not observe hand washing signs in bathroom sinks. Cough etiquette and social distancing postings were not observed in facility.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 1 shared resident’s bedroom to be at least 6 feet apart and 2 bedrooms that are single occupant. 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’ records reviewed to have updated emergency contact information.

LPA discussed and reviewed LIC 808 including Infection control procedures to be implemented: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, emergency staffing plan, PPE storage, use and training, as well as daily infection control procedures. Completed LIC 808 Mitigation Plan to be submitted to CCL by 10/28/21.

No deficiencies issued during this inspection.

Exit Interview conducted. Please submit the requested forms to Fresno CCL by: 10/28/21. The following updated forms were requested: LIC 308, LIC 309, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9020, and current lease agreement. 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: 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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