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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209016
Report Date: 11/30/2023
Date Signed: 12/19/2023 02:22:04 PM


Document Has Been Signed on 12/19/2023 02:22 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:LOURDES SENIOR CARE HOMEFACILITY NUMBER:
547209016
ADMINISTRATOR:MANCILLA, DAVILYN T.FACILITY TYPE:
740
ADDRESS:2234 EAST KAWEAH CTTELEPHONE:
(559) 802-3319
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:6CENSUS: 5DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee/Administrator (L/A) Davilyn MancillaTIME COMPLETED:
07:00 PM
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An unannounced Annual/year visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Care Giver (CG)Theresa Cumlat, introduced self & asked if Licensee/Administrator (L/A) Davilyn Mancilla was on the premises. CG stated no, but would call L/A. LPA called L/A to notify them that LPA was @ facility & purpose of visit. L/A stated that they would come to facility.

L/A joined LPA during this visit.

LPA observed 4 of 5 residents in living room watching television. Residents appeared to be appropriately dressed & groomed.

Facility toured. Dining & living rooms have required seating & lighting. Resident bedrooms toured. Bedrooms have furnishings & lighting. No unpleasant odors detected throughout facility. Observations of floors, counters, resident belongings indicating sufficient housekeeping.Fire extinguisher service date 7/14/2023.

Annual visit to be continued at a later date due to time restrictions.

Exit interview conducted with L/A. Report provided @ time of visit.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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