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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209276
Report Date: 10/19/2022
Date Signed: 10/24/2022 07:25:40 AM


Document Has Been Signed on 10/24/2022 07:25 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:DIGNITY SENIOR LIVING HOMEFACILITY NUMBER:
547209276
ADMINISTRATOR:LEONG, EMILYFACILITY TYPE:
740
ADDRESS:3043 S. CEDAR STREETTELEPHONE:
(559) 563-4896
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:6CENSUS: 0DATE:
10/19/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:David E Shipman ; Emily LeongTIME COMPLETED:
11:29 AM
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Facility Type: RCFE
Application Type: INITIAL
Capacity: 6
Census (if any clients in care): 0

COMP II Participants: David E Shipman(Applicant); Emily Leong(Administrator)
Interview Method: Telephone interview with CAB

During COMP II, Applicant/Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program description
2. Applicant and Administrator qualifications
3. Staffing requirements & Training
4. Program policies -restricted/prohibited health conditions; abuse reporting, incident reporting to CCLD; food service management; emergency procedures; activities programs
5. Grievances, Complaints, Community resources
6. Application document review and technical assistance- Criminal record clearance; Health screening; Fire clearance; First aid/CPR certificate; Financial verification; Compliance history; Control of property
SUPERVISOR'S NAME: Tracy ThompsonTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Ricmar SorianoTELEPHONE: (916) 617-7083
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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