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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206786
Report Date: 12/15/2022
Date Signed: 12/15/2022 10:55:40 AM

Document Has Been Signed on 12/15/2022 10:55 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:TRANSITIONAL LIVING CENTER #4FACILITY NUMBER:
547206786
ADMINISTRATOR:LEIGH (CABEJE), TAMARAFACILITY TYPE:
735
ADDRESS:1136 S LIBERTY CTTELEPHONE:
(559) 733-6766
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 4DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tamara Leigh, AdministratorTIME COMPLETED:
11:00 AM
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On 12/15/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and granted entry. LPA met with Michelle Terry, Case Manager and Tamara Leigh, Administrator. LPA toured facility with Case Manager and Administrator. There are four clients present during inspection.

Upon entry facility staff was observed with facial mask. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point designated for universal entry screening. Hand sanitizer was available to clients and visitors. Facility appeared cleaned with no obstruction. Social distancing is maintained in the common and dining areas.

LPA observed fire extinguisher served date: 07/01/2021. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 2 shared clients’ bed to be at least 6 feet apart. All bathrooms observed trash bin with no lid. LPA observed hand washing posting by all sinks.

Food supply was checked and appeared to be an adequate supply. Meals are served and prepared at a central location for all clients. All client’s records reviewed to have updated emergency contact information. LPA observed 30 days PPE supplies.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

An exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 12/21/22. The following updated forms were requested: Lic 308, Lic 500, Lic 610D, Lic 9020, Lic 808, Lic 9282, and current Administrator Certificate. A copy of this report and appeal rights was provided to Administrator.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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Document Has Been Signed on 12/15/2022 10:55 AM - It Cannot Be Edited


Created By: Mai Yang On 12/15/2022 at 10:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TRANSITIONAL LIVING CENTER #4
FACILITY NUMBER: 547206786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80064(a)(3)
Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Fire Extinguisher has a service date of 07/01/21, which poses an immediate health and safety risk to the clients.
POC Due Date: 12/16/2022
Plan of Correction
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Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 12/16/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022


LIC809 (FAS) - (06/04)
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