<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209088
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:45:37 PM


Document Has Been Signed on 11/27/2023 03:45 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:DAGO RESIDENTIAL FACILITY #2 ELDERLYFACILITY NUMBER:
547209088
ADMINISTRATOR:LOPEZ,TAIMIFACILITY TYPE:
740
ADDRESS:3425 S. SAN JOAQUIN CT.TELEPHONE:
(559) 799-4086
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:6CENSUS: 4DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Taimi Lopez, Administrator TIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/27/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry by staff. Administrator was contacted and arrived shortly after.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions were observed inside or outside. Common areas were properly furnished and well-lit throughout. The dining room is equipped with a table and chairs, living room is equipped with adequate sofas and recliners for four residents, adequate outside space for rest and recreational. Backyard gate is self-closing and self-latching.

7-day supply of non-perishable foods and a 2-day supply of perishable foods observed. Knives are locked in the kitchen cabinet. Cleaning and Chemical supplies are kept in locked cabinet under the kitchen sink and garage. Fire extinguisher in kitchen was serviced on 11/9/2022. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available. Carbon monoxide and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid mats in place. Fire drill conducted on 9/9/2023. Resident's records contained Personal Rights, and current Physician's Report. Resident’s files have updated emergency contact information. Staff files were reviewed for good health. It was verified that there are at least one staff on duty who is CPR certified.

No deficiencies issued during this inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/04/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with
appeal rights were provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1