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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208766
Report Date: 08/27/2021
Date Signed: 08/31/2021 04:30:21 PM

Document Has Been Signed on 08/31/2021 04:30 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:SEQUOIA ADULT ACTIVITY CENTERFACILITY NUMBER:
547208766
ADMINISTRATOR:CONLEY, LORRIEFACILITY TYPE:
775
ADDRESS:1329 N ALTA AVETELEPHONE:
(559) 315-5351
CITY:DINUBASTATE: CAZIP CODE:
93618
CAPACITY: 30CENSUS: 18DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Administrator, Lorrie ConleyTIME COMPLETED:
01:02 PM
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On 8/27/21 Licensing Program Analyst (LPA) M. Garza arrived at facility to conduct an unannounced Infection Control/Annual Inspection. LPA was met by Administrator, Lorrie Conley. LPA observed a central entry point but screening was not present for clients, staff and visitors. Clients observed in common area having lunch.

Mitigation plan was submitted 1/2021. COVID-19 procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA toured the facility inside and out. Required postings of hand washing signs observed. However, coughing etiquette and physical distancing were not observed throughout the facility. Staff not observed wearing face coverings, as they were having lunch with clients. Covered trash bins were observed. LPA observed a supply of PPE. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying were observed. Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices are found to be in compliance.

During visit LPA observed a fencing leading to neighbors yard, crawl space vents on house uncovered/broken and kitchen doorway has uneven lip with potential tripping hazard; all of these posing a potential hazard to the clients in care. Due to time constraints LPA will be returning for a Case Management.

Exit interview was completed with Administrator. Due to COVID precautionary measures a copy of this report will be sent via email with a delivered and read receipt that serves as confirmation.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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