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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206651
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:10:09 PM

Document Has Been Signed on 12/12/2022 03:10 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: 3DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Elizabeth Ewing, LicenseeTIME COMPLETED:
01:15 PM
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On 12/12/22, 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 Elizabeth Ewing, Licensee. Upon entry staff was observed wearing facial covering. LPA conducted tour with Licensee. There was one client were present during the tour.

LPA did observe visitor log-in/temperature check upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Hand sanitizer was readily available to residents and visitors. Cough etiquette and social distancing postings were observed in facility. LPA observed fire extinguisher served date: 03/19/22.

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 trash bins with lid in bathrooms. LPA observed hand washing signs in bathroom sinks.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 3 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 client’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. Please submit the requested forms to Fresno CCL by: 12/19/22. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610D, Lic 9282. LPA received copy of Licensee’s health screening. A copy of this report was provided to Licensee.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
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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